




LIBRARY OF CONGRESS. 

T\ Cv <l <q A 
G'f;.'i|i. - Coptjrigfyl "tya.. 

Shelf .Al.2- 



UNITED STATES OF AMERICA. 



Wl 





I 




PLATE I. -TYPICAL CASE OF PROCIDENTIA THROUGH ARTIFICIAL ANUS. 



-ridge CaLith Phila. 






DIAGNOSIS AND TREATMENT 



Diseases of me Rectum, Anus, 



Contiguous Textures. 



DESIGNED FOR PRACTITIONERS AND STUDENTS. 



By S. G. GANT, M.D., 

Professor of Diseases of the Rbctdm and Anus, University and Woman's Medical Colleges; Lecturer 

on Intestinal Diseases in the Scabkitt Tbaining-School for Nobses; Rectal and . sal Surgeon 

to All-Sums. German, Scarritt's Hospital for Women, and Kansas City, Fort R itt, and 

Memphis Railroad Hospitals, to East-Side Free Dispensary, and to Children and 

Orphans' Hume. Kansas City, Mo. : Member of the American Medical Associ- 
ation, National Association of Railway-Surgeons, the Mississipp 
Valley Medical, the Missouri Valley Medical, and the Mis- 
souri and Kansas State Medical Associations: of the 
Kansas dry Academi of Medicine, Jackson 
County, and of the Kansas City District 
Medical Societies, etc., etc., etc. 



WITH TWO CHAPTERS ON "CANCER" AND "COLOTOMY" 



HERBERT WILLIAM ALLIXGHAM, P.R C.S.Eng., 

Surgeon to the Great Northern Hospital: Assistant Surgeon to St. Mark's Hospital for Diseases of the 
Rectum; Surgical Tutor to St. George's Hospital, etc., etc., London. 



Illustrated with 16 FulI=Page Chromo=Lithographic Plates and 115 Wood= 
Engravings in the Text. 




1896. 



\ 






COPYRIGHT, L896, 



THE F. A. UAVIS COMPANY. 



[Registered at Stationers' Hall, Loudon, Eng.] 



Philadelphia, Pa., U. 8. A. 
Lieal Bulletin Printing-Hoose, 

1016 Cherry Street. 



THIS VOLUME 



DEDICATED BY THE AUTHOR TO HIS FATHER, 



JACKSON D. GANT, M.D., 



TOKEN OF AFFECTION. 



PREFACE. 



This treatise is the result of an effort to give to the prac- 
titioners and students of medicine a concise, yet practical, work. 
I have not attempted to give a detailed discussion of theories 
and antiquated views of unrecognized value. Of recent years 
so much has been written upon " Asepsis and Antisepsis " and 
" Rectal Reflexes " that I have deemed it best not to set apart 
separate chapters for these subjects, but have given them suf- 
ficient attention throughout the entire work. Two chapters 
have been written that are new in a work of this kind, — one 
on " Railroading as an Etiological Factor in Rectal Diseases " 
and one on ;; Auto-Infection from the Intestinal Canal." I 
have given these subjects distinct chapters of their own, for [ 
am sure that their importance has been very much underrated 
by writers generally. 

In words in which the diphthong is employed I have made 
use only of the vowel sounded ; thus, in the words hcemorrhoids, 
forces, diarrhoea, etc., I have omitted the superfluous ones, 
spelling them thus : hemorrhoids, feces, and diarrhea. In 
order to present a comprehensive work I have made frequent 
reference to the standard works on diseases of the rectum and 
anus and to reprints and monographs too numerous to mention. 
Among the text-books which I have consulted I desire to 
mention the following : Allinghani, Mathews, Cripps, Kelsey, 
Cooper and Edwards, Van Buren, Ashton, Curling, Ball, 
Quain, Henry Smith, and Bodenhamer on hemorrhoidal dis- 
ease. I have, in each instance, endeavored to give proper credit 
to authors, and if I have failed in a single case it has been 
unintentional. 

Now comes the pleasing duty of expressing mv indebted- 

"(v) 



VI PREFACE. 

ness to professional friends who have rendered me valuable 
assistance. 

I was fortunate, indeed, in getting Mr. Herbert William 
AUingham, of St. Mark's Hospital, London, to write two 
chapters on " Cancer " and " Colotomy," for I doubt if there is 
any man living more capable of dealing with these important 
subjects than he. 

I wish also to acknowledge my obligations to Dr. J. C. 
Stewart for valuable assistance rendered in helping me to per- 
fect the many original diagrams and drawings seen throughout 
the work ; and to my friends, Drs. W. F. Kuhn and Daniel 
Morton, for correcting my manuscript. To my publishers, 
The F. A. Davis Co., I wish to express my gratitude for the 
many courtesies received. To The Burk & McFetridge Co., 
the gentlemen who made the many beautiful chromo-litho- 
graphic plates, I will only say that the excellency of their 
work has surpassed by far my most sanguine expectations. 
Trusting that my labors may prove to be of some practical value 
to the profession, I respectfully submit it for their perusal. 

S. G. G. 

Kansas City, Mo., 

March, 1896 



TABLE OF CONTENTS. 



CHAPTER I. PAGE 

Introductory, 1 

CHAPTER II. 

Anatomy and Physiology of the Rectum and Anus, 3 

CHAPTER III. 
Symptomatology, 12 

CHAPTER IY. 

Examination or the Rectum and Anus, . . , . .19 

CHAPTER V. 

Congenital Malformations of the Rectum and the Anus, . 28 

CHAPTER VI. 

Prolapse of the Rectum, . .41 

CHAPTER VII. 
Polypi and Other Non-malignant Growths, 54 

CHAPTER VIII. 
Syphilitic Affections, 62 

CHAPTER IX. 

Proctitis and Periproctitis, 65 

CHAPTER X. 
Rectal and Anal Fistulas, 72 

CHAPTER XL 

The Relation of Pulmonary Tuberculosis to Fistula, . . 99 

(vii) 



Mil CONTENTS. 

CHAPTER XII. PAGE 

Incontinence of Feces, 106 

CHAPTER XIII. 
Fissure and Painful Ulcer, Ill 

CHAPTER XIV. 
Ulceration, . 130 

CHAPTER XV. 
Benign Stricture, 146 

CHAPTER XVI. 

Histology, Etiology, Differential Diagnosis, and Prognosis of 

Hemorrhoids, 180 

CHAPTER XVII. 
External Hemorrhoids, , . .185 

CHAPTER XVIII. 
Internal Hemorrhoids, 191 

CHAPTER XIX. 

Treatment of Internal Hemorrhoids, ...... 194 

CHAPTER XX. 
Hemorrhage from the Rectum 229 

CHAPTER XXI. 
Pruritus Ani (Itching Piles), 235 

CHAPTER XXII. 

Diarrhea and Discharges, 241 

CHAPTER XXIII. 

Constipation 253 



CONTENTS. IX 

CHAPTER XXIV. PAGE 

Impaction of Feces, , . . ,266 

CHAPTER XXV. 

Auto-infection from the Intestinal Canal, . % . . . 268 

CHAPTER XXVI. 

Cancer of the Rectum : its Etiology, Symptoms, Varieties, and 

Treatment, 291 

CHAPTER XXVII. 

COLOTOMY, 308 

CHAPTER XXVIII. 

Artificial Anus and Fecal Fistulas, 359 

CHAPTER XXIX. 

Wounds and Injuries, . 362 

CHAPTER XXX. 

Neuralgia of the Rectum, ........ 366 

CHAPTER XXXI. 

Sodomy (Pederasty), 372 

CHAPTER XXXII. 

Railroading as an Etiological Factor in Rectal Diseases, . 379 



Index, 393 



TABLE OF CASES. 



CASE PAGE 

I. Prolapsus due to summer diarrhea, 51 

II. Extensive prolapsus of all the rectal coats, 51 

III. Extensive prolapsus, 53 

IV. Dwarfed child suffering from prolapsus, .52 

V. Large fibrous polypus of several years' standing, 59 

VI. Adenoid polypi, 59 

VII. Horseshoe fistula, 94 

V11I. Blind internal fistula, 97 

IX. Tubercular fistula, 104 

X. Tubercular fistula, 105 

XI. Incontinence due to rupture of sphincter muscle, 109 

XII. Painful ulcer from constipation, 128 

XIII. Painful ulcer with bladder complications, 128 

XIV. Painful ulcer within external pile, 129 

XV. Ulceration of the rectum, 143 

XVI. Ulceration of the rectum, 144 

XVII. Tubercular ulceration, 145 

XVIII. Stricture due to a muscular band, 171 

XIX. Stricture of the rectum, 173 

XX. Stricture of the rectum with almost complete obstruction, .... 175 

XXI. Stricture of the rectum, 177 

XXII. Stricture due to fibrous band, 178 

XXIII. External hemorrhoids (thrombotic variety), 188 

XXIV. External hemorrhoids (thrombotic variety), 189 

XXV. External hemorrhoids (cutaneous variety), 189 

XXVI. External hemorrhoids complicated with fissure, 190 

XXVII. Internal hemorrhoids treated by the injection method, .... 206 

XXVIII. Internal hemorrhoids complicated with prolapse. Clamp-and-cautery 

operation, ............. 226 

XXIX. Internal hemorrhoids complicated with ulceration. Ligature operation, . 227 

XXX. Pruritus ani (aggravated case), 240 

XXXI. Chronic diarrhea caused by ulceration, 251 

XXXII. Chronic diarrhea caused by rectal polypi, 252 

XXXIII. Stick in the rectum ; death from peritonitis, 362 

XXXIV. Neuralgia of the rectum, 369 

XXXV. Neuralgia due to scar-tissue 370 

XXXVI. Neuralgia due to a dislocated coccyx, 371 



00 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Office-table, 20 

2. Office-table in Sims's position, .......... 21 

3. Office-table in lithotomy position, 22 

4. Hinged speculum, 23 

5. Sims's wire speculum, 24 

6. Mathews's speculum, ............ '24 

7. Esm arch's chloroform inhaler, 25 

8. Pratt's bivalved operating- speculum, 25 

9. Cook's trivalved operating speculum, 26 

10. Author's artificial light and table apparatus, 20 

11. Narrowing of the anus without complete occlusion, 29 

12. Closure of the anus by membranous tissue. ........ 30 

13. Imperforate auus, the rectum terminating far above in a blind pouch, ... 31 

14. Imperforate anus, the rectum opening into the vagina, 33 

15. Imperforate anus, the rectum terminating in the bladder, 34 

16. Imperforate anus, the rectum terminating in the urethra, 35 

17. Imperforate anus, the rectum opening- on the surface by means of a fistulous 

sinus through the penis, ........... 36 

18. Imperforate rectum, the anus natural, but rectum separated from it by mem- 

branous partition, ............ 38 

19. Diagrammatic drawing showing prolapse of the rectum, ..... 41 

20. Prolapse of the mucous membraue, 42 

21. Partial prolapse of the rectal coats, 44 

22. Prolapsus ani truss, 4S 

23. Rectal plug, 4S 

24. Kelley pad used in operations about the rectum 49 

25. Dwarfed child suffering from extensive prolapse of the rectum, .... 53 
20. Adenoid (soft) polypus, 55 

27. Removal of polypus high up with the author's clamp 56 

28. Fibrous (hard) polypus, 57 

29. Pen sketch of fibromata, from photograph of case, 58 

30. A. Complete fistula. B. Blind internal fistula, . 75 

31. A. Blind external fistula. B. Complete internal fistula, 76 

32. A. Complete external fistula. B. Recto-vaginal fistula, 77 

33. Horseshoe fistula, 78 

34. A. Recto-vesical fistula. B. Recto-urethral fistula, 79 

35. Allingham's elastic ligature carrier, S4 

36. Steel gorget, 86 

37. Allingham's scissors and groove director, ........ 86 

3S. Proper method of using Allingham's scissors and director, ..... ST" 

39. Mathews's fistulatome, 89 

40. Author's angular groove director for blind internal fistula, ..... 89 

41. Hoi'seshoe fistula with multiple openings, ........ 95 



(xi) 



XI] LIST OF ILLUSTRATIONS. 

FIG. PAGE 

12. Lines of incisions showing how the external sinuses were made to communicate 
with each other and with the rectum and the sphincters severed but oner, and 

then at a right angle 96 

b>. Appearance of the anus where the sphincter was cut in three places in a girl 

who recovered perfect control of the bowel in six weeks, 107 

44. Ideal anal dilators (half size), 126 

45. insufflator, 140 

4ti. A-llingham's ointment applicator, 140 

47. Sims's irrigator and drainage-tube, 141 

48. Diagrammatic drawing- of annular stricture, 146 

-1'.). Diagrammatic drawing of tubular stricture, 146 

50. Appearance of a cross-section of strictured rectum, 148 

51. Bodenhamer's rectal explorer, ........... 162 

52. Correct method of introducing a rectal bougie, 168 

53. Whitehead's dilator, 169 

54. Durham's dilator, 169 

55. Set of " Aloes " bard-rubber bougies, 169 

56. Wales's soft-rubber rectal bougies, 170 

57. Appearance of gut before removal, 177 

58. Artificial anus one year after operation, 178 

59. Showing attachment of internal hemorrhoids, ....... 193 

60. Hemorrhoidal truss, 194 

61. Cross-section of internal hemorrhoids, 195 

82. Pollock's hemorrhoidal crusher, 198 

63. Herbert Allingbam's pile-crusher, 198 

64. Cautery irons, 200 

65. Cautery blow-pipe, 201 

66. Thomas's curved tissue-forceps, 212 

67. Correct method of applying the ligature, ........ 213 

68. Clover's crutch, 214 

69. Mathews's pile-forceps, 215 

70. Paquelin cautery, 216 

71. Smith's clamp. 217 

72. Dilatation of the sphincter ani, 218 

73. Severing the mucous membrane from the skin, 219 

74. Cauterizing the stump, 220 

75. Author's pile and polypus clamp, 222 

70. Benton's India-rubber tampon. (Modified by Edwards), 233 

77. Drainage-tube wrapped with gauze, 233 

78. Hollow vulcanite drainage-tube, .......... 234 

79. Herbert Allingbam's method of excision of rectum, ...... 301 

80. Herbert Allingbam's method of excision of rectum, 302 

81. Herbert Allingbam's method of excision of rectum, 303 

82. Relations of peritoneum with mesentery, 320 

83. Relations of peritoneum with mesenteiy, 321 

8-1. Relations of peritoneum with mesentery 321 

85. Longitudinal bands and appendices epiploic*, 322 

86. State of gut with varying mesenteries 324 

87. State of gut with varying mesenteries, 324 

88. State of gut with varying mesenteries, 324 

State of gut with varying mesenteries, 324 

90. State of gut with varying mesenteries, 324 



LIST OF ILLUSTRATIONS. Xlll 

FIG. l'AGK 

91. State of gut with varying mesenteries, 324 

92. Suturing gut, 328 

93. Gut after operation, 329 

94. Removal of gut, . 330 

95. Double-barreled opening, 331 

96. Showing double-barreled opening with directors passed into each orifice, . . 331 

97. Mesentery as cause of procidentia, 333 

98. Procidentia, .... 333 

99. Mesentery made taut, ............ 334 

100. Gut pulled out to full extent, 334 

101. Herbert Allinghanrs colotomy clamp, 335 

102. Removal of gut with above clamp, 335 

103. Fecal fistula, 339 

104. Artificial anus, 339 

105. Procidentia from upper opening, 340 

106. Procidentia from lower opening, .......... 341 

107. Procidentia from both openings, 342 

108. Position of peritoneum in condition 1, 348 

109. Position of peritoneum in condition 2, 349 

110. Position of peritoneum in condition 3, 350 

111. Procidentia from both openings after lumbar colotomy, ..... 354 

112. Procidentia from both openings after lumbar colotomy, ...... 355 

113. Stick removed from rectum (half size), 363 

114. Diagrammatic drawing showing deviation of coccyx anteriorly 367 

115. Diagrammatic drawing showing deviatiou of coccyx posteriorly, . . . 367 



LIST OF FULL-PAGE PLATES. 



PLATE PAGE 

I. Typical case of procidentia through artificial anus (frontispiece). 
II. Levatores ani as seen from above, .9 

III. Levatores ani, side-view, 9 

IV. Typical case of procidentia recti, 11 

V. Syphilitic condylomata, 62 

VI. Typical case of recto-vesical fistula, showing- result of extravasation of urine 

into scrotum and penis, 78 

VII. Typical case of fistula in auo, with operation for same, 86 

VIII. Painful ulcer (fissure) of the anus, 118 

IX. Ulceration and polypoid-like sentinel teats, 130 

X. Diagrammatic drawing of stricture of the rectum due to ulceration, . . . 156 
XI. Artificial anus, showing one opening into rectum and the other into descending 

colon, 175 

XII. Thrombotic hemorrhoid, 185 

XIII. Pathology of internal hemorrhoids, 191 

XIV. Protruded hemorrhoids, with prolapsed mucous membrane, .... 193 
XV. Author's clamp adjusted and scissors in position for excision of hemorrhoids, . 217 

XVI. Typical case of fibrosarcoma with multiple fistula, involving the rectum and 

anus, operated on by the author at his clinic, .... 307 and 308 



(xiv) 



Diseases of the Rectum, Anus, and 
Contiguous Textures. 



CHAPTER I. 
INTRODUCTION. 



In the whole range of surgical pathology no other class 
of diseases among civilized communities is so prevalent, causes 
more suffering, and induces so many varied reflex and distress- 
ing sympathetic affections as the diseases occurring about the 
anus and rectum. This is because of the structure of the anus 
and rectum, their peculiar office in the economy of nature, and 
their relation to the important organs in their immediate vicinity. 
Happily for the sufferers, no other class of complaints succumbs 
more readily to judicious and, in the majority of cases, to simple 
treatment, when properly applied at the onset of the disease. 
Unfortunately, from mistaken delicacy or carelessness, patients 
often postpone seeking proper advice until the local symptoms 
have become unbearable or the constitution seriously deranged ; 
or, from the prominence and severity of some one of the reflex 
or sympathetic effects, they are induced to adopt a variety of 
empirical remedies which fail in the restoration of health and 
are often productive of pernicious results. Many of these dis- 
eases spring from irregularities in habit engendered by sedent- 
ary pursuits, or they result from indulgence in the luxuries of 
civilized life. They are, therefore, more prevalent in the middle 
and upper circles of society ; though they are not infrequently 
found in all classes. 

Diseases of the rectum have been mistaken for prostatic, 
uterine, and cystic affections. This renders a careful examina- 

a) 



2 DISEASES OF THE RECTUM AND ANUS. 

tion, both visual and digital, absolutely necessary. Unless the 
surgeon understands the anatomy of the parts he cannot com- 
prehend the physiology of the rectum, much less the diseases 
to which it is liable. When well acquainted with it and the 
surrounding parts, he not only performs the operation with 
more deftness, but is enabled to understand the functions of the 
several organs and their mutual relations. Therefore, the sub- 
ject of the following pages cannot be introduced in a more use- 
ful manner than by briefly describing the anatomy of the rectum 
and its relation to the several organs contained in the pelvis. 



CHAPTER II. 

ANATOMY AND PHYSIOLOGY OF THE RECTUM 
AND ANUS. 

It is not our intention to go into the minute anatomy of 
the rectum and the anus, but to give such information that the 
operator may work with a degree of intelligence. The inferior 
portion of the colon and alimentary canal is called the rectum, 
— a misnomer in the human species ; the term originated prob- 
ably from the usual straight form that this organ presents in 
the lower animals. The length varies from six to eight inches 
(15 centimetres to 2 decimetres), the latter measurement 
being more common in advanced life, for as age increases the 
tortuosity of the bowel is more marked. Above it is continu- 
ous with the terminal portion of the sigmoid flexure of the 
colon, situated in the left iliac fossa, and terminating below at 
the anus. In rare instances the position of the abdominal vis- 
cera is reversed ; in such cases the rectum would necessarily 
commence on the right side. At its commencement it curves 
downward toward the right side of the pelvis three and one- 
half inches (8.8 centimetres), by which it is brought to the 
median line of the sacrum at a point opposite the third sacral 
vertebra ; it then descends obliquely forward and downward 
for about three inches (7.5 centimetres), at which point it is 
found opposite the apex of the coccyx ; from this point it turns 
upon itself, backward and downward, for about one and a half 
inches (3.8 centimetres), thus completing its course at the anus. 
It is obvious, in introducing the finger into the rectum, that it 
should be passed upward and forward. Like the hollow ab- 
dominal viscera, the rectum has three coats, — peritoneal, mus- 
cular, and mucous, — the first being only partial, w T hile the 
others are continuous throughout. Ordinarily it is that portion 

(3) 



4 DISEASES OF THE RECTUM AND ANUS. 

which is not covered by peritoneum that is the seat of the 
disease. 

Peritoneal Coat. 

The upper portion of the rectum is in contact with the 
sacrum, internal pudic, and sacral plexus, in front with the pos- 
terior portion of the bladder in the male, and with the uterus 
in the female. Sometimes a convolution of the small intestine 
may intervene. At its commencement the rectum is generally 
surrounded by the peritoneum, which binds it to the sacrum ; 
but lower down it covers the anterior surface only, and is then 
reflected on to the bladder, forming the recto-vesical pouch. 
The uterus and vagina are interposed between it and the blad- 
der in the female. This pouch may extend down to within an 
inch (2.54 centimetres) of the prostate; the distance is liable to 
variations depending on the age and the distension of neighbor- 
ing organs. In the newborn it may extend to within an inch 
(2.54 centimetres) of the anus. The distance increases after 
the fifth year ; in old age with enlarged prostate the peritoneum 
goes still higher up. The distance from the anus to the lower 
portion of the fold has been a subject of much controversy both 
at home and abroad. We shall not enter the discussion, but 
will state that our observations lead us to believe that two and 
a half inches (6.35 centimetres) in the male and three and a 
half inches (9.9 centimetres) in the female, with an additional 
inch (2.54 centimetres) when both bladder and rectum are dis- 
tended, would be a fair average distance. 

Muscular Coat. 
This coat is thicker and stronger than other portions of the 
large intestine. It consists of two layers, — viz., circular or inner 
and longitudinal or outer. The fibres of the latter are partly 
prolongations of the colon, while some are peculiar to the 
rectum. They are more numerous in the anterior and posterior 
portions of the rectum, and by their action prevent the rectum's 
being thrown into folds as in the colon. They also seem to be 



ANATOMY AND PHYSIOLOGY OF THE RECTUM AND ANUS. 5 

more abundant in the upper than in the lower portion. The 
circular fibres are neither particularly strong nor numerous in 
the upper portion, but become stronger and more abundant at 
the lower end of the rectum. There they form a muscular 
band, about an inch (2.5-1 centimetres) in width, constituting 
the internal sphincter muscle. 

Mucous Membrane. 

The mucous membrane is thicker and more vascular than 
any other portion of the large intestine. It contains many 
mucous follicles, which are distinct. It glides over the tissues 
beneath and is so abundant as to be gathered into folds, which 
diminish in proportion as the bowel becomes distended. Ex- 
tending from one fold to another, at times little arches may be 
seen forming small poc'kets, which are at the present writing 
the subject of much controversy. It is well to observe them 
closely, however, for it is an easy thing to mistake the mouth 
of one of these pockets for that of a blind internal fistula. 
The introduction of a probe will quickly settle the diagnosis 
and determine if it be a fistula or not. These follicles are very 
numerous and, under the microscope, present a honey-comb 
appearance. They prove of great value from their absorbing 
power, — a. fact demonstrated by the good results derived from 
rectal medication. Sometimes enlarged papillae are to be seen 
about the anal margin. 

Arterial Supply. 

The arteries of the rectum are derived from three distinct 
sources : — 

1. The superior hemorrhoidal, from the inferior mesenteric. 

2. The middle hemorrhoidal, from a branch of the internal 

iliac. 

3. The inferior hemorrhoidal, from the internal pudic after 

it has re-entered the pelvis. 



6 DISEASES OF THE RECTUM AND ANUS. 

The Superior Hemorrhoidal. — This artery divides into 
two branches, which course along the posterior wall of the 
rectum. They are at first superficial, but soon perforate the 
longitudinal fibres and give off a number of branches, which 
anastomose on the internal surface of the rectum, not only with 
each other, but with the middle and frequently with the inferior 
hemorrhoidal arteries. The main branches run parallel with 
the bowel. This accounts for the smallness of the hemorrhage 
from incisions made in the long axis and the profuseness of 
the same made at a right angle to the long axis of the bowel. 

Jfiddle Hemorrhoidal Arteries. — They vary in size and 
take an oblique course downward to supply the middle third 
of the rectum. 

Inferior Hemorrhoidal Arteries. — They send branches 
upward as well as downward to anastomose with the other 
hemorrhoidal arteries to supply the levator ani, sphincter 
muscles, and cellular, fatty, and tegumentary tissues in the anal 
region. 

Veins of the Rectum. 

The veins correspond in name with the arteries. The 
middle and inferior hemorrhoidal return the blood from the 
anal region to the internal iliac. The hemorrhoidal plexus of 
enlarged and anastomosing veins is situated in the lower part 
of the rectum and from it proceeds the " superior hemorrhoidal 
vein," which returns the blood from the rectum proper to the 
portal system. This vein and its branches pass upward under 
the mucous membrane for a distance of about three or four 
inches (7.62 or 10.16 centimetres), then perforate the muscular 
coat, and can be seen on the outside of the bowel. Verneuil 
has laid much stress on this anatomical fact, claiming that the 
veins pass through muscular button-holes, which have the 
power of contracting around them, closing their calibre and 
preventing a return of the blood to the liver. In this anatom- 
ical arrangement, he believes, is to be found the active cause 
of internal hemorrhoids. 



anatomy and physiology of the rectum and anus. 7 

Nerves of the Rectum. 
They are derived from the two great classes which go to 
make up the nervous system, — the cerebro-spinal, from the sys- 
tem of animal life, and the sympathetic, or system of organic 
life. The former are from the sacral plexus and the latter from 
the mesenteric and hypogastric plexuses. The muscles of the 
anal region are supplied by branches of the sacral nerves, while 
the superficial perineal of the pudic supplies the levator ani 
and skin in front of the anus. The inferior hemorrhoidal (of 
the pudic) branch supplies the lower end of the rectum and 
anus. The pudic is controlled by the same part of the cord as 
the sciatic. Hence irritation from a fissure or ulcer located 
within the anus may be transferred down the limbs or to other 
distant parts. Mr. Hilton alludes to pain in the heel as a fre- 
quent symptom of fissure. The intimate relation of this nerve 
to the genito-urinary organs explains the frequency with which 
disorders of micturition are associated with rectal affections. 
The upper and middle portions of the rectum are much less 
sensitive than the lower, as has been proven by experiments 
made by Bodenhamer. The pain increases in proportion as 
the disease encroaches upon the anal margin ; hence disease, 
malignant or otherwise, situated high up may cause little pain. 
The sympathetic nerve is distributed to the rectum and anus 
and is derived from the hypogastric, which is formed by 
branches from the aortic plexus. It also receives branches 
from the lumbar and sacral plexuses. 

Lymphatics. 
The absorbents of the rectum and anus are much more 
numerous than is generally supposed. They consist of two 
systems, those of the anus being distinct from those of the rec- 
tum, the former going to the inguinal and the latter to the 
sacral and the lumbar glands. This accounts for the clinical 
fact of infiltrated inguinal glands from a similar condition in 
the rectum. Mr. Cripps, however, has recorded two cases of 



8 DISEASES OF THE RECTUM AND ANUS. 

infiltrated inguinal glands when the seat of the disease was 
situated high up in the rectum. 

The x\nus. 

The anus is a small oval orifice, directed downward and 
backward, situated about an inch (2.54 centimetres) in front 
of the extremity of the coccyx, between the tuber ischii (but 
above them in the male), in the median line between the but- 
tocks. It is covered internally by integument, which is firm, 
soft, and provided with papillae, hair, and sebaceous follicles. 
The latter secrete an unctuous fluid with an unpleasant odor. 
The anus can be freely dilated, but, when closed, the surround- 
ing skin is thrown into numerous folds. 

Muscles of the Rectum and Anus. 

The muscles that especially interest us in the study of 
rectal diseases are three in number, — viz., the external and 
internal sphincters and the levator ani. 

External Sphincter. — This muscle is situated immediately 
beneath the integument. It arises from the tip of the coccyx. 
After surrounding the anus in the form of an ellipse, it is in- 
serted in front into the central tendon of the perineum. The 
action of the muscle is to close the anus and assist in the ex- 
pulsion of the feces in conjunction with the expiratory muscles. 
Its contracting power varies in different people and under cer- 
tain pathological conditions. For example, it will be found 
firmly contracted when a fissure is present. In most cases of 
malignant diseases it is loose and flabby. We always antici- 
pate serious rectal diseases when there is no sphincteric resist- 
ance to the introduction of the finger. 

Internal Sphincter. — This muscle is a flat, involuntary, 
muscular band lying immediately above the external sphincter. 
It is from three-fourths of an inch (1.9 centimetres) to one 
inch (2.54 centimetres) in breadth and one-sixth inch (4.2 




PLATE II-LEVATORES AMI AS SEEN FROM ABOVE 




PLATE III.-LEVATORES ANI, SIDE VIEW 



ANATOMY AND PHYSIOLOGY OF THE RECTUM AND ANUS. 9 

millimetres) in thickness. Its fibres are somewhat paler than 
those of the internal. United with this muscle are the un- 
striped bands, which arise from the anterior surface of the 
coccyx (recto-coccygeus muscle). The recto-coccygeus muscle 
embraces the lower end of the rectum in a fork, and it draws 
the rectum upward toward the apex of the coccyx, when it is 
forced down during the act of defecation. 

Levator Ani. — The origin and insertion of this muscle, as 
well as its action, have been the subject of much study and 
controversy. From the dissections which we have made we 
believe, with Mr. Cripps, that a large portion of the fibres 
arises from the inner surface of the symphysis and from half 
an inch (1.27 centimetres) of the anterior portion of the white 
line, and passes obliquely downward and backward to be in- 
serted on the sides of the coccyx. The fibres cross the rectum 
at right angles two and a half inches (6.35 centimetres) above 
the anus. (See Plates II and III.) 

The action of the levator ani is to compress the sides of 
the rectum and the neck of the bladder, and in the act of defe- 
cation, when the sphincter contracts to open the anus, it closes 
the urethra. This explains in part the well-known difficulty 
of discharging urine and feces at the same time. We have 
made two diagrammatic drawings (see plates) which show very 
nicely the relation of the levator ani to the rectum. 

This muscle also partly forms the floor of the pelvis to 
support the pelvic organs. In addition to this it has a volun- 
tary sphincteric action, which can be demonstrated by intro- 
ducing the finger into the bowel and requesting the patient to 
draw up the anus as much as possible, when a contraction may 
be felt from one and a half to two inches (3.8 to 5.08 centi- 
metres) above the anus. This Mr. Cripps attributes to the lev- 
ator ani. This action would, in part, account for the control 
of the bowel that is frequently seen after complete destruction 
of the sphincters. Again, after certain rectal operations where 
the sphincters have been thoroughly paralyzed, patients often 



1 DISEASES OF THE RECTUM AND ANUS. 

complain of the anus's jerking. This we attribute to the action 
of this muscle. 

The Rectum. 

The rectum differs from other portions of the large intes- 
tine in that it has no longitudinal bands and it is non-saccu- 
lated in appearance. When distended to its fullest capacity it 
fills a large portion of the pelvic cavity. Internally it presents 
three or four transverse folds. According to Houston,* the 
largest one is situated three inches (7.62 centimetres) above the 
anus, opposite the base of the bladder ; the second, at the upper 
end of the rectum ; the third, midway between the two just 
named; while the fourth (rarely present) will be found one 
inch (2.54 centimetres) above the anus. They form, as it were, 
valves which occupy from one-third to one-half the circumfer- 
ence of the bowel, the margins of which are directed upward ; 
they are located on opposite sides, thus forming a kind of spiral 
tract, the object of which is to support the fecal mass and pre- 
vent a too rapid descent to the anus. The folds become almost 
obliterated when the bowel is distended. From the study of 
the anatomy we necessarily are led to the consideration of the 
physiology of the rectum and anus, to which attention is now 
invited. 

Physiology of the Rectum and Anus. 

It is a noticeable fact, to those accustomed to making rectal 
examinations, that the rectum is found to be empty, in a large 
percentage of cases, until just before defecation takes place. 
The prevailing opinion seems to be that the fecal mass is ar- 
rested and supported, in the upper part of the rectum, by the 
folds previously described, till just before expulsion of the 
same takes place. There has been and still is much contro- 
versy as to what produces the sensation which precedes the ex- 
pulsion. Some claim it to be due to contact. This is hardly 
probable, for we have seen large masses collect where no sensa- 

* Dublin Hospital Reports, vol. v, p. 158. 



ANATOMY AND PHYSIOLOGY OF THE RECTUM AND ANUS. 11 

tion was felt whatever. Others ascribe it to some irritant pro- 
duced in the retained feces. This appears less reasonable than 
the other, for we know that the sensation is produced immedi- 
ately on the discharge of the fluid feces into the rectum in cases 
of diarrhea. While I am not positive as to what causes the 
sensation, I am inclined to believe it is of an organic nature, 
as a result of some intestinal change which takes place before 
the mass reaches the rectum. The peristaltic movements which 
precede defecation are increased by sphincteric resistance. At 
the proper time, however, the muscle relaxes and, by the aid 
of the abdominal muscles (especially the internal oblique and 
diaphragm), together with the levator ani, the fecal mass is ex- 
pelled. The frequency of the evacuations depends largely upon 
habit and diet. Actions occur more frequently in males than 
in females. Normally the bowel ought to act at least once in 
every twenty- four hours. It is not an uncommon occurrence, 
however, to see patients who do not have an action more than 
once in three or four days or even a week without the use of 
some medicine. This delay is often due to irregular habits in 
going to the stool. 



CHAPTER III. 
SYMPTOMATOLOGY. 

Before taking up for consideration the individual rectal 
diseases we desire, in a general way, to give the symptoms 
which one would be likely to meet in the treatment of this 
class of diseases, and to note their value as a guide to correct 
diagnosis. Among the more prominent ones we might men- 
tion are: pain, which may be confined to the neighborhood of 
the pelvis or reflected up the back or down the limbs ; dis- 
charges of blood, pus, or mucus ; protrusions, constipation, 
diarrhea, and itching about the anus. 

Pain. 

Pain may vary from a slight discomfort to intense pain. 
In getting the history it is well to inquire if it is constant, dull, 
or sharp in character ; if it is about the anal margin or high in 
the rectum, as well as its relation to defecation, to find out if 
it precede, accompany, or follow it ; also as to its duration, 
and accordingly some idea may be formed as to the nature of 
the disease. Pain may be expected when any of the following 
conditions are present : — 

1. Fissure. 3. Ulceration. 

2. Hemorrhoids. 4. Morbid growths. 

Fissure. — In fissure the pain is very severe and out of all 
proportion to the extent of the lesion. It usually comes on 
during the act of defecation, is most intense during the same, 
and lasts for some time afterward. It is described as being 
of a hot, smarting character, severe, and radiating toward the 
coccyx. 

Hemorrhoids, — Pain due to hemorrhoids depends on the 
size of the tumor, the location, and the amount of the inflam- 
(12) 



SYMPTOMATOLOGY. 1 3 

mation present. External piles, unless inflamed, cause very 
little pain. The only inconvenience is a sensation of fullness 
and heat. If the pile chance to be of the thrombotic variety, 
there will be much pain and tenderness until the clot is turned 
out. 

Internal Hemorrhoids. — Like the external variety, they 
often produce a sensation of heat and fullness ; the pain will be 
more or less severe, depending upon the size, number, and 
location of the tumors. Should there be only one or two 
tumors situated above the grasp of the sphincter, they will 
cause very little annoyance; while if they are large and within 
the grasp of the sphincter to such an extent as to become 
strangulated, the pain will be intense and of a drawing and 
burning character, with a constant desire to strain down, which 
results in the tumors' swelling and acting as foreign bodies. 
They keep the sphincter in a state of spasmodic contraction 
in its endeavor to expel the same. Should the tumors continue 
to fill and the strangulation is not relieved, ulceration will prob- 
ably occur, inducing additional pain, which is likely to continue 
until the piles have been operated upon or taken nature's course 
and sloughed off. 

Ulceration. — In ulceration of the rectum the amount of 
pain depends upon the location and extent of the disease. If 
it is situated high up and is not too extensive, there will be 
a minimum amount of pain. On the other hand, when it is 
located near the anal margin, the pain is very great ; in fact, it 
increases in severity as the anal margin is encroached upon. 

Malignant Disease. — Pain in malignant disease, like that 
of ulceration, depends largely upon the extent and location of 
the disease, being much greater when situated low down. It 
increases as the disease becomes more fully developed. Much 
pain will be experienced every time the hardened feces pass 
over the diseased parts to be expelled, and after a time patients 
suffer from alternate attacks of constipation and diarrhea. 
During the latter the pain is of a smarting, burning character, 



14 DISEASES OF THE RECTUM AND ANUS. 

and the straining almost unbearable. Strange to say, in some 
cases of malignant disease, even though it be extensive, little 
pain is experienced. This occurs only when the disease is 
located high up in the rectum. Because of the slight pain the 
surgeon, in all probability, will not be called until the disease 
has progressed to such an extent that little can be done. 

Protrusions. 

In getting the history it is desirable to find out if anything 
protrude from the anus. If so, ascertain if the protrusion oc- 
cur during defecation only or at irregular times, if it return of 
its own accord or if the patient return it himself, if it is con- 
stantly present, and if it is accompanied by hemorrhage. A 
protrusion, under such circumstances, might be the result of a 
variety of diseases, viz. : — 

1. Prolapsus recti. 3. Polypi. 

2. Internal hemorrhoids. 4. Villous growths. 

Prolapsus. — The tumor, in cases of prolapsus, is soft and 
smooth. The color of the mucous membrane and the whole 
circumference of the bowel is involved. Its size depends upon 
the extent of the prolapsed bowel. As a rule, it induces little 
suffering unless strangulation has taken place. 

Internal Hemorrhoids. — The protrusion of internal piles 
can be distinguished from that of prolapsus in that the tumor 
or tumors are distinct and do not involve the entire circum- 
ference of the bowel. There will be very little pain until 
strangulation takes place ; then the pain and the swelling- 
become exaggerated. At an early stage of the disease the 
tumors come down, but can be readily replaced ; while in cases 
of long standing they remain outside the anus nearly all the 
time. 

Polypi. — A polypus, like an hemorrhoidal tumor, usually 
comes out during defecation, the extent of which depends upon 
the length and size of the pedicle. It may return spontane- 



SYMPTOMATOLOGY. 15 

ously or have to be returned by the patient himself. This 
sometimes becomes impossible, when strangulation occurs, and 
then it sloughs off. 

Villous Tumors. — These are vascular in character, but 
resemble the others just described, in that they are made to 
protrude during defecation. 

Hemorrhage. 

In the order of frequency as a symptom, hemorrhage 
comes next to pain. The blood may be voided pure or min- 
gled with feculent matter, or appear in streaks on the surface 
of hardened feces. Mucoid discharges tainted with blood are 
frequently to be seen. Hemorrhage of the rectum may be a 
symptom of any of the following diseases : — 

1. Internal hemorrhoids. 7. Pol} T pi. 

2. Prolapsus. 8. Villous growths. 

3. Fissures. 9. Wounds and the presence of 

4. Ulceration. foreign bodies in the rectum. 

5. Stricture. 10. Hemorrhage from the stomach. 

6. Malignant disease. 

Internal Hemorrhoids. — The amount of hemorrhage de- 
pends upon the case. It is usually started by straining during 
stool. In one case only a few drops will escape, while in an- 
other the flow may be very profuse ; in others there may be 
a continuous dropping for hours after stool. The hemorrhage 
is usually of a venous character. We have on several occa- 
sions, however, witnessed hemorrhages which were apparently 
arterial in character. It is not essential that the tumor pro- 
trude in order to have bleeding. 

Prolapsus. — Hemorrhage is of rare occurrence in cases of 
prolapsus unless ulceration is present. 

Fissures. — In fissures of the anus bleeding is usually scant. 
It follows defecation, is of short duration, and is more fre- 
quently to be seen in streaks on the hardened feces. 



16 DISEASES OF THE RECTUM AND ANUS. 

Ulceration. — In this disease the bleeding depends some- 
what upon the extent of the ulceration and its location. The 
discharge rarely consists of pure blood, but of blood mixed with 
muco- purulent matter. Sometimes it can be seen in splotches 
on the feces. In the more severe cases it may become alarming, 
especially in cases of rapidly spreading, specific, or malignant 
ulceration. 

Stricture. — Stricture accompanied by bleeding is of fre- 
quent occurrence. When mixed with pus the discharge re- 
sembles coffee-grounds to a certain- extent, especially when it 
has been retained in the rectum for a considerable length of 
time. 

Malignant Disease. — In this disease bleeding almost inva- 
riably takes place. In the early stage the bleeding is due to 
congestion and is slight ; but when ulceration commences, it 
may be profuse and either venous or arterial in character or 
both. It may occur in the intervals of defecation. Several 
cases of death from the bleeding of these growths have been 
reported. 

Polypi. — Hemorrhage from polypi is rare and is seldom 
profuse. 

Villous Growths. — In these growths the bleeding may 
occur during, preceding, or following the act of defecation. 
It is usually slight, but at times becomes profuse. 

Wounds and Foreign Bodies. — Hemorrhage in these cases 
depends entirely upon the location and extent of the injury. 

Stomach. — In cases of hemorrhage of the stomach where 
the blood has not been vomited up, it may pass downward 
and be discharged from the rectum. Such discharges are of 
a blackish color, and may be mistaken for indications of some 
rectal disease. 

Constipation. 

The next symptom in point of frequency is constipation. 
There is nothing specially characteristic about this symptom, 



SYMPTOMATOLOGY. 17 

for it may be a result of sluggish peristaltic action or of a great 
variety of other pathological conditions, such as : — 

1. Fissures. 4. Impaction of feces. 

2. Stricture. 5. Compression of the rectum. 

3. Malignant growths. 

When caused by fissures it is owing to the patient's defer- 
ring defecation as long as he possibly can on account of the 
pain it induces. It is sometimes a symptom of impacted feces 
or compression of the rectum. Frequently it is a result of 
pressure from a misplaced uterus, enlarged prostate, or a tumor 
of some kind. Constipation is usually the first symptom to 
manifest itself in stricture of the rectum, due to the impedi- 
ment. It may be more or less severe, according to the tight- 
ness of the constriction. It very nearly always alternates with 
diarrhea in cases of malignant stricture, when fully developed. 

Diarrhea. 

Diarrhea and discharges from the bowel form a group of 
symptoms met with in many diseases occurring in the rectum. 
We think that in all cases of suspected rectal disease a careful 
examination should be made of the excreta to ascertain if it 
is natural in shape and consistence, for various unnatural dis- 
charges, such as blood, pus, mucoid secretions, and elements of 
tissue, will be found therein. Diarrhea may appear as a symp- 
tom of 

1. Ulceration. 2. Stricture. 

Diarrhea may be a symptom of any form of rectal ulcera- 
tion which becomes extensive. It is worse on arising in the 
morning and after exercise or exposure to cold. The discharge, 
which resembles coffee-grounds, may be mixed with muco-pu- 
rulent matter and blood. In cases of stricture the diarrhea 
frequently alternates with constipation. The actions are more 
frequent, scanty, and fluid in character than in ulceration. 



IS DISEASES OF THE RECTUM AND ANUS. 

Diarrhea is almost invariably present in malignant disease, and 
it is not infrequently a symptom of impaction, from the fact that 
the watery portions may pass around the fecal mass and be dis- 
charged. Mucoid and purulent matters may be discharged at 
times in varying quantities. They can be recognized by their 
color and very peculiar odor. 

Feces. — A close examination of the feces will frequently be 
of service in making a diagnosis. Their shape may be altered 
when the calibre of the bowel is constricted from any cause, es- 
pecially when it occurs low down. In appearance, under such 
circumstances, the feces may resemble pipe-stems ; again they 
may be grooved or flattened and ribbon-like. When soft, the 
alteration may be due to a spasmodic contraction of the sphinc- 
ter ; hence, this change is not always indicative of organic dis- 
ease. iVgain, in cases where the constriction is located high up, 
the feces may accumulate below it and be discharged compara- 
tively normal in shape and size. Their shape may be altered 
from an enlarged prostate, which has been known to cause 
total obstruction, or from an impaired sphincter, because of 
their not being retained until well formed, for we know that 
fecal incontinence is not an infrequent complication of rectal 
cancer and sometimes occurs in cases of prolapsus of long 
standing. 

Pas. — Pus may be discharged from the bowel because of 
the bursting of an abscess, rectal inflammation, internal piles, 
ulceration, and in cases of stricture. The quantity may be large 
or small and the color light or dark, depending upon the extent 
of the lesion and the other discharges intermingled with it. In 
this connection we might add that mucoid discharges are present 
in cases of prolapsus, invagination, and villous growths, while 
tissue-elements and debris are found in the stool where extensive 
ulceration is present. 



CHAPTER IV. 

EXAMINATION OF THE RECTUM AND ANUS. 

Having considered the symptomatology of rectal diseases 
and their diagnostic import, it now remains for us to describe 
the best methods of examining the rectum which will give us 
the most information concerning cases coming to us for treat- 
ment. No patient should be prescribed for until both a visual 
and a digital examination has been made. Because a patient 
says he has piles or fistula and his family physician affirms the 
diagnosis, we should not be deterred from making: a careful 

© - © 

examination in each case to find out just what disease we have 
to combat. Those of us who treat a large number of these 
cases know what absurd mistakes both physicians and patients 
frequently make as regards a correct diagnosis. The blame in 
many instances should be placed upon the physicians, many of 
whom are only too glad to confirm the patient's diagnosis with- 
out the trouble of making an examination and proceed to pre- 
scribe some ointment or lotion when they are ignorant of the 
real disease. 

It is not an easy matter, in many cases, to get patients to 
submit to an examination, especially women. We have made 
a rule to have nothing to do with such persons unless they do 
consent, for treatment carried on in the dark will prove unsatis- 
factory, both to the patient and to the physician. If possible, 
the examination should be preceded by a thorough cleaning out 
of the bowel by some laxative followed by an enema. Unless 
this precaution is taken, when the speculum is introduced a 
view of the upper portion of the rectum may be obstructed by 
an accumulation of feces. 

Position. 
For an ordinary examination we much prefer the semi- 
prone of Marion Sims. The patient is placed on the left side 

(19) 



20 



DISEASES OF THE RECTUM AND ANUS. 



on a rather high table, the right shoulder turned away from the 
surgeon, the left arm brought backward from under the body, 
and the right thigh flexed upon the abdomen. The office-table 
used is so constructed that by pressing on a pedal the head can 
be lowered and the hips elevated. In addition to this, it can be 
rotated from side to side, thus enabling one to view the parts at 
a great advantage. It is the best all-round table we know of. 
It is manufactured by the W. D. Allison Company, of Indian- 
apolis. (See Figs. 1, 2, and 3.) 




Fig. 1.— Office-Table. 



We do not think the Marion Sims position the best one 
for making an examination high up in the rectum. For this 
we prefer the genu-pectoral, especially for men. Sometimes we 
have patients stand in the erect position and strain down. In 
this way the diseased parts will be brought nearer the anus, 
thus enabling us to reach an inch or two higher up. Gentle- 
ness should always be used when making a rectal examination. 
By so doing much pain and annoyance can be avoided. Before 
the finger is introduced into the rectum a careful examination 



EXAMINATION OF THE RECTUM AND ANUS. 



21 



of the external parts should be made. By separating the but- 
tocks a good view of the anus and surrounding parts can be 
had. Cracks, fissures, external hemorrhoids, excoriations, and 
discharges, when present, can be readily detected. 

The finger should then be slowly passed around the anal 
margin to detect any deep-seated or superficial hardness, which 
may be due to a fistula or abscess formation. Tenderness in 




Fig. 2.— Office-Table in Sims's Position. 



the neighborhood of the anus can be readily detected in the 
same way. Eruptions of any kind — eczematous, syphilitic, or 
otherwise — will also be noticeable. Next, a careful examination 
of the interior of the rectum should be made. The finger 
should be anointed with vaselin or some other stiff lubricant. 
The patient is then requested to bear down gently and by a 
boring motion the finger is passed forward and upward very 
slowly and gently. Much depends upon the tact used in making 



22 



DISEASES OF THE RECTUM AND ANUS. 



the examination, for, when it is exceedingly painful, we have 
known patients to defer an operation, laboring under the mis- 
taken idea that, if a simple examination caused so much pain, 
the operation would be unbearable. Much valuable information 
to the educated finger can now be obtained. First, notice the 
strength of the sphincter. A tight sphincter indicates a fissure, 
while a weak one is suggestive of malignant or other grave 




Fig. 3— Office-Table in Lithotomy Position. 



rectal disease. Then, by sweeping the finger around the rectal 
wall, internal hemorrhoids, internal fistulous orifices, fissures, 
ulceration, polypi, strictures, and morbid growths can be easily 
detected. Next, the prostate gland and the uterus must be 
examined, for when they press on the rectal wall they are liable 
to induce some pathological condition of the same at any time. 
If a tumor of any kind should be located, determine if it be 



EXAMINATION OF THE RECTUM AND ANUS. 23 

hard or soft and, if possible, remove a small portion for micro- 
scopical examination to determine its character ; in more than 
one case a fecal impaction has been mistaken for a cancer of 
the rectum. On withdrawal, if there be any discharge on the 
finger, examine it and see whether it is blood, pus, or mucus. 

Speculums. 

The question of what speculum is best for rectal examina- 
tions is not of so much importance as one who does little work 
in this department of surgery would at first suppose. We use 
the speculum less and less every year in the preliminary exami- 




Fig. 4.— Hinged Speculum. 

nation, for. in cases where a diagnosis cannot be made after a 
thorough digital and visual examination of the outer parts when 
the buttocks have been separated and the anal margin pulled 
apart, it is difficult to make it with the aid of any of the specu- 
lums now in use unless an anesthetic is given. When we have 
a doubt as regards the diagnosis, we at once insist on a thorough 
examination under chloroform, that we may determine the exact 
condition of the parts. In cases where an anesthetic is not 
given, and it is desirable to use a speculum for the effect or other 
reasons, we prefer a small, cone-shaped, hinged one (Fig. 4). 
which we have used for several years with more satisfaction 



24 DISEASES OF THE RECTUM AND ANUS. 

than any of the others, of which we have a great variety. Next 
to this we use Sims's wire or Mathews's speculum. (See Figs. 
5 and 6.) 




Fig. 5.— Sims's Wire Speculum. 



Examination under Anesthesia. 

Examinations under an anesthetic are always satisfactory 
as far as the diagnosis of the local condition is concerned, for 
under chloroform or ether the irritable sphincter relaxes and a 




Fig. 6.— Mathews's Rectal Speculum. 



complete view can be had of the seat of the disease in cases 
where pain and spasm of the sphincter would otherwise offer 
almost insuperable obstacles to a complete exploration of the 
parts. The sphincter should be thoroughly divulsed ; then, 



EXAMINATION OF THE RECTUM AND ANUS. 



25 



by the aid of the improved speculums now in use and a good 
light, the lower four or five inches (10 or 12 centimetres) of 
the rectum can be seen easily, which makes the diagnosis of 




Fig. 7. — Bsmarch's Chloroform Inhaler. 



to-day easy in comparison with the difficulties which had to be 
overcome in former years. We use Pratt's bivalved speculum 
(large size) or Cook's trivalved speculum, to the exclusion of 




Fig. 8. — Piatt's Bivalved Operating Speculum. 



all others, for examinations conducted under chloroform, and 
for operations where a . speculum is indicated. (See Figs. 8 
and 9.) 

In our office we use an artificial light which consists of an 



26 



DISEASES OF THE RECTUM AND ANUS. 



ordinary incandescent electric light fitted in a reflector similar 
to those used by throat specialists, attached to a dental bracket 




Fig. 9.— Cook's Trivalved Operating Speculum. 



in such a way that it can be raised, lowered, or turned at any 
angle. (See illustration.) I devised it some four years ago, 




Fig. 10.— Author's Artificial Light and Table Apparatus. 

and it has given perfect satisfaction and, in addition to this, 
does away with the use of an instrument- table. With this 



EXAMINATION OF THE RECTUM AND ANUS. 27 

light and the aid of a pair of vulsellum forceps, with which to 
draw the gut down, a good view can be had of the entire cir- 
cumference for five inches (12.7 centimetres) or more. When 
a growth is suspected high up which cannot be diagnosed by 
other means, the hand and arm may be inserted into the rectum 
and, by so doing, the diagnosis may be made clear. This is 
accomplished more easily in the female than in the male. The 
hand should be small, and then introduced cone-shaped with 
the greatest caution, for cases have been reported where the 
rectum has been ruptured in this way, resulting in death. Mr. 
Allingham, Sr., says that in one case he diagnosed and com- 
pletely broke up a false membrane of peritoneum which was 
holding down the bowel as it crossed the brim of the pelvis, 
and the patient made a complete recovery. The danger from 
this method of diagnosis is that of rupturing the bowel, owing 
to the walls' being weak from ulceration. In concluding an 
examination it is always necessary to press deeply into the left 
iliac fossa to determine the presence of tenderness or a tumor 
of any kind. 



CHAPTEE V. 

CONGENITAL MALFORMATIONS OF THE RECTUM AND 

THE ANUS. 

Congenital malformations of the rectum and the anus are 
of comparatively rare occurrence ; still, it is essential that all 
medical men should be familiar with the different varieties and 
the treatment required. While some malformations can be re- 
lieved easily, others cannot be helped by the surgeon. Rectal 
malformations result from arrested fetal development of the 
rectum and anus in early fetal life. We shall not have the 
space to give in detail the development of the lower bowel 
in this volume, a full detail of which can be found in sys- 
tematic works on embryology. There are many varieties of 
malformations ; and nearly all authors vary some in their 
classification. 

We are of the opinion, however, that the most simple 
and practical classification is that of Holmes, with slight 
modifications, as given by Cooper and Edwards, which is as 
follows* : — 

Imperforate Anus. 

" Congenital narrowing of the anus without complete 
occlusion, but sometimes accompanied by a fecal fistula. 

" Closure of the anus by membranous tissue. 

" Entire absence of the anus, the rectum ending in a blind 
pouch at a varying distance from the perineum. 

" Imperforate anus with fecal fistula opening either into 
the vagina, male bladder, urethra, or upon the surface of the 
body." 

* Diseases "f Rectum and Amis, by Cooper and Edwards, page 44. 

(28) 



congenital malformations of rectum and anus. 29 

Congenital Narrowing of the Anus without Complete 

Occlusion. 

Narrowing of the anus or rectum without complete occlu- 
sion comprises the least serious form of the preceding classifi- 
cation. The anal aperture is at times preternaturally small, 
either in consequence of a contraction of the lower end of the 
rectum or from the skin's extending over the border of the 
anal margin. The outlet may be sufficiently large to let the 




Fig. 11.— Narrowing of the Anus without Complete Occlusion. 

meconium drain away, or so small that an escape of the excre- 
mentitious matter is impossible. (See Fig. 11.) 

The symptoms, when pronounced, will be vomiting and 
abdominal distension ; when only slight, constipation and a dif- 
ficulty in voiding the feces only will be noticed. The diagnosis 
is usually easy, for the contraction is near the anus and can be 
readily detected with the finger, or it can be seen when due to 
a fold of skin extending, across the anus. 

Treatment. — The treatment consists in dividing the ring or 
skin with a bistoury on the dorsal surface, after which the parts 



30 



DISEASES OF THE RECTUM AND ANUS. 



should be thoroughly cleansed and antiseptic dressings applied. 
The ringer or a soft-rubber bougie should be inserted into the 
bowel daily, covered with balsam of Peru, to keep the opening- 
well dilated and the wound in a healthy condition. Any fistu- 
lous openings into the vagina generally close up after the outlet 
has been made sufficiently large to allow the excrementitious 
matters a free exit. 

Closure of Anus by Membranous Tissue. 

The second variety of imperforate anus also constitutes one 
of the simpler forms. The anus may be well formed and the 




Fig. 12.— Closure of the Anus by Membranous Tissue. 

bowel continuous, but the meconium is retained by a mem- 
branous partition (see Fig. 12) which stretches across the 
rectum above the anus. This membrane may vary in thickness, 
but is usually thin. The diagnosis is made by digital exami- 
nation or by the aid of a probe ; from the retention of the 
meconium and the bulging of the bowel, it is clearly visible 
when the child cries. Spontaneous rupture has been known to 
occur, thus affording an exit to retained matters. 



CONGENITAL MALFORMATIONS OF EECTUM AND ANUS. 



31 



Treatment. — Something' should be done at once or the oc- 
clusion may result in increasing abdominal distension, vomiting 
of the meconium, collapse, and death. A free incision should be 
made through the centre of the membrane, which will be followed 
by a discharge of the bowel-contents, affording relief at once. If 
the finger is inserted into the anus daily, tampons to separate 
the anal walls can be discarded. Sphmcteric power is usually 
well developed in these cases ; consequently patients have little 
difficulty in retaining the feces after the operation. In cases 
where the end of the rectum does not extend so far down as the 
anus, it should be drawn down and stitched to the anal mars-in. 




Fig. 13.— Imperforate Anus, the Rectum Terminating Far Above in a Blind Pouch. 



Entire Absence of Anus. 

In this class one may expect to find some of the most diffi- 
cult cases of congenital malformation, though some are com- 
paratively simple. Instead of a normal anus, the tissues extend 
across the anus from one side to the other, and the rectum may 
terminate quite a distance above the normal site of the anus. 
(See Fig. 13.) The intervening space may be made up of 
connective tissue, while a circular elevation or depression marks 



32 DISEASES OF THE RECTUM AND ANUS. 

the natural site of the anus. In many of these cases the pelvic 
measurements will be considerably reduced. The diagnosis is 
made by pressing the abdominal contents down with one hand, 
while palpation is being made to the perineum with the other to 
ascertain if the distended pouch can be located or any impulse felt. 
If the perineum and the pouch are more than an inch (2.54 centi- 
metres) from each other, no impulse can be felt; while if it be less 
the impulse can usually be detected. In females an examination 
per vagina will at times be of material service in locating the 
pouch. If symptoms are not urgent, one is justified in delaying 
the operation, to see if the sac will not become so distended that 
its exact location can be determined. 

Treatment. — When the pouch has been located, an incision 
should be made in the median line from the centre of the 
perineum to the tip of the coccyx, and all tissues dissected down 
until the tense pouch is reached, opened, brought down, and the 
edges sutured to the walls of the incision somewhat similar to 
the operation for inguinal colotomy, being careful that the edges 
of the mucous membrane and skin are carefully united. Then 
cleanse the parts thoroughly with some antiseptic solution and 
put on dry antiseptic dressings, which should be removed daily 
and a bougie inserted and retained for some time, that too much 
contraction may not follow. If the pouch is situated high up, 
or if its location cannot be determined, the operator should so 
state the circumstances to the parents, and with their consent at 
once perform left inguinal colotomy, being careful to make a 
good spur and to see that the skin is well sutured to the mucous 
membrane so that a prolapsus will not occur. It is well to 
remember that, in children, the sigmoid may be located on the 
right side. This anatomical arrangement may be the cause of 
some difficulty in locating the gut. 

Imperforate Anus with Fecal Fistula. 

In this class the anus is absent, but a communication 
exists between the rectum and the vagina in the female (see 



CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 



33 



Fig. 14), the urethra or bladder in the male (see Fig. 15), or 
between the bowel and the surface of the body at some point 
near the anal region. 

FECAL FISTULA TERMINATING IN THE VAGINA. 

When the fecal fistula terminates in the vagina the open- 
ing will be larger than when it terminates in the urethra and 
will be found in the posterior or lateral wall ; the exit in such 
a case is frequently so large that the meconium and contents 




Fig. 11. — Imperforate Anus, the Rectum Opening into the Vagina. 

of the bowel can be discharged and distension is prevented. 
Women have been known to live to an advanced age with this 
malformation without being conscious of any abnormality. As 
a rule, however, they suffer very much from pain, ulceration, 
and excoriations of the parts. 

Treatment. — -The treatment is comparatively simple. A 
probe or groove director is passed through the recto-vaginal 
aperture to a point in the perineum where it is intended to 
make the anus ; it is then cut down upon. The rectum should 



34 



DISEASES OF THE RECTUM AND ANUS. 



then be brought down and sutured and the opening in the 
vagina closed. Some encourage the laying open of all the 
tissue from the fistula to the natural anal position and let heal- 
ing take place by granulation. Others pare and suture the 
edges of the opening in the pouch to those of the skin. It 
seems to us that, so long as the patient does not suffer from 
distension and can control the bowels satisfactorily, operative 
interference is uncalled for. 




Fig. 15.— Imperforate Anus, the Rectum Terminating in the Bladder. 



FECAL FISTULA TERMINATING IN THE URETHRA. 

Imperforate anus with the rectum opening into the bladder 
or urethra is a tar more serious condition. When it opens 
into the urethra, the opening is usually very small. (See Fig. 
16.) Naturally, this occurs more frequently in the male than 
in the female, on account of the length and the narrowness of 
the urethra. The opening is always very small ; the meconium 
is unable to pass out, and at an early period distension is 
noticeable. The watery portion of the rectal contents oozes 
out at first, but as the feces acquire consistency obstruction 
will take place, and the life of the patient becomes endan- 



CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 



35 



gered. In an exceptional case, recorded by Mr. Page,* the 
patient, a man 54 years old, had throughout his life voided 
his feces and urine by the urethra. Soon after birth the 
imperforate anus was discovered, and an attempt was made to 
establish an opening in the natural position, which did not 
prove a success. At the age of 10 obstruction occurred, and 
temporary relief was afforded by incising the urethra in front 
of the scrotum. Through this opening he, with difficulty, dis- 




Fig. 16.— Imperforate Anus, the Rectum Terminating in the Urethra. 

charged his feces and urine with the assistance of aperient medi- 
cines for some time. Contraction of the fistula and the block- 
ing of the urethra finally led him to seek relief; but he refused 
assistance further than an enlargement of the fistula, although 
Mr. Page found that a probe could be passed through the anal 
aperture. The urethra was accordingly split up and the mucous 
membrane sutured to the skin, thus converting the fistula into 
an opening of fair size. Four months afterward the patient 



* British Medical Journal, vol. ii, pp. 875-SSS. 



36 



DISEASES OF THE RECTUM AND ANUS. 



reported that lie was comfortable and that his bowels acted 
regularly without medicine. Many other interesting cases have 
been reported where the bowel-contents have been discharged 
by the urethra for a greater or less period of time, causing little 
annoyance in some, while others suffered greatly, living for 
months until obstruction occurred and death ensued. 

Treatment. — When this form of malformation exists an 
operation for obtaining an exit at the natural site should not be 
delayed, owing to the serious symptoms which accompany dis- 
tension. The operation is performed by cutting down through 




Fig. 17.— Imperforate Anus, the Rectum Opening on the Surface by Means of a 
Fistulous Sinus through the Penis. 

the natural site of the anus until the pouch is reached, opened 
and sutured to the skin, and the fistula closed. In some cases 
the rectum opens into the bladder and, in such cases, the 
meconium and urine will be mixed and voided through the 
urethra. The child may survive for a short time, but a fatal 
termination is almost certain unless something is done, although 
cases are on record where adults have continued to discharge 
their feces through the urethra with comparatively little incon- 
venience. There is very little to be done from an operative 
stand-point, further than to keep the urethra dilated sufficiently 
that the contents may escape, unless we do a colotomy. 



CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 37 

FECAL FISTULA OPENING UPON SURFACE OF BODY. 

Imperforate anus with fecal fistula opening upon the sur- 
face of the body presents a variety of forms, the openings being 
differently situated ;. there may be one or a number of them ; 
the most common site is some point in the perineum. If the 
opening is small and obstruction has taken place, make an 
incision with a probe-pointed bistoury, enlarging the opening 
in the median line or as near as possible. Then, if the edges 
of the rectum can be brought down to the margin of the wound 
and sutured, a fine result may be looked for. The opening at 
times may be located in the scrotum, the base of the penis, the 
gluteal, or lumbar, or sacral regions. 

Treatment. — The treatment differs according to location. 
The principal feature, however, is to establish the outlet at or 
as near to the natural seat of the anus as can be done. If pos- 
sible, unite the edges of the skin and mucous membrane. Not 
infrequently an operation is impossible ; then the only thing to 
be done is to enlarge the fistula to such a degree that the con- 
tents may be discharged with as little discomfort to the patient 
as possible. While operative interference does not meet with 
as much success as we could desire, yet much comfort can be 
rendered the patient and life made at least worth living. 

Imperforate Rectum. 
It now remains to consider the cases belonging to this 
class, — viz., those in which the rectum is imperforate, but the 
anus is in the natural position. These, according to the classi- 
fication adopted, may be divided into two classes. In the first 
of these the obstruction in the rectum is membranous in char- 
acter. (See Fig. 18.) In the second there is a total deficiency 
or an extensive obliteration of the rectum. The attention of 
the surgeon is not called to these cases, as a rule, until the symp- 
toms have become urgent, from the fact that the anus is in the 
normal position. The attendants naturally look elsewhere for 
a cause of the symptoms until distension occurs. I have myself 



38 



DISEASES OF THE RECTUM AND ANUS. 



seen a case of this kind in hospital practice, due to a mem- 
branous septum extending completely across the rectum about 
one inch (2.54 centimetres) above the anus, which was readily 
detected by the introduction of the ringer into the anus. I at 
once incised the membrane, washed out the bowel, and left a 
small rubber bougie to be passed daily for a few weeks. The 
child completely recoverd. When the obstruction is due to a 
membrane, this treatment should be carried out under antiseptic 
precaution and success will follow. In the second class, where 




Fig. 18. 



-Imperforate Rectum, the Anus Natural, but Rectum Separated from it by a 
Membranous Partition. 



the rectal pouch may be situated too high to get any impulse, 
the child's life is in great danger. 

Treatment. — The operative procedures at our command 
are two ; first, by dissecting up to the gut from the perineum ; 
second, performing colotomy at once, for the child must have 
immediate relief. If, after a thorough examination, the pouch 
seem to be within reach, the former may be tried; but if there 
is reason to believe that the pouch is so high up that it cannot 
be reached or that the rectum is abnormally developed, a 



CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 39 

colotomy should be resorted to at once. When the artificial 
anus has been once established, if the indications should 
warrant it, an attempt can be made to restore the anus at 
the normal site. Dr. Byrd, of St. Louis, operated on a case 
of this kind by introducing a sound through the artificial anus 
and pushing the pouch downward in order to more easily reach 
it from below. He made an incision about two inches (5 centi- 
metres) deep upward from the anus and back to the coccyx large 
enough to permit the passage of the index finger. The sound 
was then carried downward until within one-eighth of an inch 
(3 millimetres) of the finger passed from below. When it could 
pass no farther with ease, it was forced through the intervening 
tissues and out the anus. In the after-treatment much ingenuity 
was displayed in trying to get the mucous membrane toward 
the opening, but the subsequent history was not given. It was 
thought that the artificial anus would close without further 
operative procedures than the wearing of a well-fitting pad. 
Cases have been reported where the opening in the groin was 
closed with success, while others were not so fortunate. 

In bringing this chapter to a close, we desire to mention 
that the death-rate in cases of malformation is high, even in 
simple cases where only a puncture has been made, though not 
so high as where, owing to the liability to constriction, an 
attempt has been made to establish an artificial anus at the 
natural site. 

The following table is taken from Cripps, and shows the 
mortality in one hundred cases operated on by him : — 

1. Colon opened in the groin, . . . .16, died 11 

o u U u u u 3 " 2 

3. Puncture, IT, " 14 

4. Cocc^yx resected, 8, " 5 

5. Perineal incision or dissection, . . .39, " 14 

6. Communication between rectum and vagina, 14, " 1 

7. Miscellaneous, 3, " 3 

Total, 100 " 50 



40 DISEASES OF THE RECTUM AND ANUS. 

This report shows a death-rate of 50 per cent. This 
certainly is not encouraging, yet, on the other hand, probably 
all would have died if an operation had not been performed. 

In this chapter we have not attempted to treat of any 
varieties of malformations except those of the most frequent 
occurrence. Those desiring a more lengthy description of the 
varieties and treatment of malformation of the rectum and anus 
we respectfully refer to the excellent works of Bodenhamer, 
Curling, Cripps, and Ball. 



CHAPTER VI. 

PROLAPSE OF THE RECTUM. 

Prolapse of the rectum lias been very improperly denomi- 
nated prolapsus ani by many high in authority. Since the anus 

is merely an aperture with a fixed point, it cannot therefore be 
prolapsed. It may be everted to a certain extent, but it cannot 
be prolapsed. Prolapsus of the rectum signifies the descent of 
a portion of the bowel through the anus, which, in the normal 




Fig. 19. — Diagrammatic Drawing showing Prolapse of the Rectum. 

state, is within and above that aperture, the protrusion consisting 
of mucous membrane, either alone or combined with other coats 
of the rectum. Between these extremes there are many inter- 
mediate varieties. Again, we may have the upper portion of 
the rectum invaginated into the lower. From a practical stand- 
point we have three varieties of prolapsus of the rectum, viz. : — 

1. Prolapse of the mucous membrane alone. 

2. Prolapse of the rectal coats, and, when extensive, the 

peritoneum will be pulled down as well. 

3. Prolapse of the upper portion of the rectum into the 

lower, called invagination or intussusception. 

(4i) 



4*2 



DISEASES OF THE RECTUM AND ANUS. 



Prolapsus of the Mucous Membrane. 

This we have found to be the most frequent variety. (See 
Fig. 20.) During normal defecation the narrow ring of mucous 
membrane protrudes from the anus, which returns when the act 
is completed. This is quite noticeable among some animals, 
as the horse. It occurs more frequently among children than 
adults. 

Causes. — The acute cases are found in children, and are 
usually produced by straining at stool, as a result of constipation 




Fig. 20.— Prolapse of the Mucous Membrane. 



or diarrhea, especially in those of a tubercular diathesis. Phi- 
mosis and stone in the bladder not infrequently cause this con- 
dition, as a result of the constant straining during micturition. 
In children, owing to tbe straightness of the sacrum, prolapsus 
is more liable to occur. Relaxation of muscles and of other 
structures may also bring about this condition. Prolonged or 
violent coughing or screaming may also produce prolapsus; 
paralysis and ulceration of the sphincter may cause it; polypi, 
internal hemorrhoids, or other foreign bodies in the rectum 



PROLAPSE OF THE RECTUM. 43 

which produce straining may be classed as causes. The pro- 
lapsus may be immediate, as a result of coughing, vomiting, 
etc., or it may come on gradually. The more often the bowel 
comes down, the more the parts become stretched and relaxed, 
thus favoring a repetition of the prolapsus. 

Symptoms. — In recent and mild cases the protruded portion 
consists of a ring of mucous membrane, which comes down 
about one inch (2.54 centimetres) when the bowels move, and 
returns spontaneously, or by the patient's assistance, after the 
act is completed. At times there is much pain and the protruded 
mass is red and bloody. This is especially so if there be any 
ulceration. Otherwise there will be no pain, and the tumor will 
be of a deep-red color and marked by crescentic folds. When 
considerable time has elapsed after the protrusion first occurred, 
it may become congested and difficult to return. In cases of 
long standing the protruded mass is easily reducible on account 
of the weakened sphincter, but will not remain long at a time. 
Prolapse may be distinguished from a polypus by its softer feel- 
ing, uniform, smooth, appearance, and the absence of a pedicle; 
but it is not always so easy to differentiate between protruded in- 
ternal hemorrhoids and prolapsus. A careful examination with 
a practiced eye and touch will allay any doubt, however. In 
prolapse we have a tumor that involves the entire circumference 
of the bowel and has a soft, velvety feel. In other respects it 
resembles the normal mucous membrane and has a slit in 
the centre of the protruded portion ; while the hemorrhoidal 
tumors, hard or smooth and lubricated, are always separate and 
distinct, have a definite feel, and are more easily movable. 

Prolapse of the Rectal Coats. 

This form of prolapsus (see Fig. 21) does not occur nearly 
so frequently as the first variety. It differs from it in that the 
protruded mass is composed of all the coats of the rectum and 
the peritoneum as well, when it is extensive. When the prolapse 
extends down more than two and one-half inches (6.35 centi- 



44 DISEASES OF THE RECTUM AND ANUS. 

metres) it is well to look out for folds of peritoneum ; for within 
there may be coils of the small intestine. This variety comes 
on more gradually than the other and occurs less frequently in 
children than in adults. The protrusion is pyriform in shape 
and at the lower extremity a slit-like opening may be seen, sur- 
rounded by folds of the mucous membrane and portions of the 
muscular coat. In this variety there is no invagination. This 
can be determined by following up the tumor (see Plate IV) 
with the finger and it will be found to be continuous with the 
rectal coat. When invagination is present a deep sulcus can 
be detected between the annular ring and the protruding mass. 



Fig. 21.— Partial Prolapse of Rectal Coats. 

This variety is the least likely to be confounded with hemor- 
rhoids or polypi. A complete examination will at once reveal 
the condition present. Complete prolapse may assume very 
great proportions, for in rare instances the greater portion or the 
entire colon may be protruded through the anus.* 

Symptoms. — The symptoms are similar to those of the first 
variety, but are of a more aggravated form ; the pain is not 
severe, as the lower portion of the mucous membrane has a low 
state of sensibility. Mucus is almost constantly discharged, and 
it is mixed with pus when ulceration is present. The most 
marked symptom, however, is the incontinence of feces, which 
is present, to a greater or less degree, in all severe cases. Compli- 

* Ball's Diseases of 1 tectum and Anus, p. 195. 




if 









PLATE IV.-TYPICAL CASE OF PROCIDENTIA RECTI. 



EurkS MTetridge Co.Lith Phila. 



PROLAPSE OF THE RECTUM. 45 

cations of complete prolapse are to be watched, the chief danger 
being due to the envelopment of the peritoneal coat. When 
this coat comes down, it is liable to contain coils of the small 
intestine or one of the ovaries. They are to be looked for in 
the anterior half of the prolapse. As a rule, when a loop of 
the small intestine is included, it can be detected by feeling it 
slip on pressure. When present this condition can be properly 
designated hernia of the rectum, and noted as such. According 
to Allingham, when hernia is present, the opening of the gut is 
always directed toward the sacrum, and, when reduced, it im- 
mediately returns to its normal position. Another complication 
to be looked for is the spontaneous rupture of the rectal wall, 
for several such 'cases are on record. 

Prolapse op the Upper Portion of the Pectum 
into the Lower. 

In treating this variety Kelsey substitutes the term invag- 
ination for 2 )r °l a P se i which he thinks more aptly expresses the 
condition. We prefer, however, to speak of it as a prolapse 
and differentiate between it and the other varieties referred to. 
In the first and second varieties the lower portion of the rectum 
slips down through the anus, while in this form the lower 
portion of the rectum retains its normal position and the upper 
portion is telescoped through it. The lower portion of the 
bowel may come down in the upper part and remain there, or 
in extreme cases protrude from the anus a great distance. The 
diagnosis can be made by passing the finger around the invagi- 
nated mass within the bowel. When the protrusion is small 
and of recent date, it can be replaced easily, though it is likely 
to appear again when the bowel acts. In cases of extreme pro- 
trusion replacement becomes difficult and painful ; but after it 
has existed for a time the anus becomes patulent and the 
sphincter loses its elasticity so much that every time the bowels 
move or the patient makes the slightest exertion the mass pro- 
trudes, thus rendering life almost unbearable. 



46 DISEASES OF THE RECTUM AND ANUS. 

Prognosis. — In giving a prognosis in any case of prolapse 
it is well to bear in mind that, when the mucous membrane 
alone is involved, a spontaneous cure is frequently effected. 
Simple remedies, however, often assist nature to a speedy cure. 
In severe cases no such happy results may be looked for, espe- 
cially in the aged. In old cases, where thickening has taken 
place, nothing short of a surgical procedure will effect a cure, 
and this may have to be repeated. So it is not well to commit 
one's self as to the time it will require to effect a cure. 

Treatment. — It matters not with which variety you are 
dealing; an effort must be made to return the mass. This 
usually can be accomplished without an anesthetic, in the fol- 
lowing manner : Place the patient, if a child, across the mother's 
knee, face down ; if an adult, he may be placed in a similar 
position on a table or bed with the head lowered. First clean 
all the protruded mass and place a soft, clean, well-oiled cloth 
over it ; then make gentle pressure over the whole mass of the 
tumor for several minutes, endeavoring to reduce the size of the 
mass by pressing out any fluid in the rectal coats. Next, en- 
deavor to return the more central part of the mass first, since it 
was the last part to come down. The reduction can be accom- 
plished in many cases with very little difficulty. To prevent 
the bowel's coming down immediately after the reduction, apply 
pressure for some time to the anus ; for this we prefer cotton- 
wool, a pad of gauze, or a soft sponge supported by a T-bandage. 
In case the mass has become swollen and painful, chloroform, 
which will materially assist in the reduction of the same, may 
be administered. After the reduction the patient should rest in 
bed with the nates drawn together tightly. We well remember 
seeing a number of cases treated by Dr. Seneca D. Powel, while 
we were house-surgeon in the New York Post-Graduate Medical 
School and Hospital. The following is his plan of treatment : 
After pulling the two buttocks together, he places strong straps 
of adhesive plaster, which are to be worn all the time, from one 
to the other. After defecation the parts are cleaned and new 






PROLAPSE OF THE RECTUM. 47 

straps substituted. We have never seen this plan fail when 
used by him. In our own practice we have found this pro- 
cedure to be of great assistance in many cases. The piaster 
proves beneficial from the fact that it supports the sphincter 
during the intervals of defecation and diminishes lateral trac- 
tion while in the squatting position. In cases where it is not 
advisable to use the straps or other support, the patient should 
be required to defecate in the recumbent position, using a bed- 
pan, or else he should occupy the erect posture. The bowel 
should be trained to act just before bed-time, thus enabling the 
patient to lie down immediately thereafter. In all cases of pro- 
lapsus an examination should be made to ascertain if there is 
any other local pathological condition, such as hemorrhoids or 
polypi, that would be likely to keep up an irritation or produce 
straining. If there is it must be corrected, else the treatment 
inaugurated for the cure of the prolapse will prove to be of no 
avail. The treatment is : — 

1. Palliative. 2. Radical. 

In children the palliative will usually prove satisfactory. 
The first thing to do is to look after the general health, and if 
a tonic is indicated it should be prescribed at once. Next, 
direct attention to the bowel and see that the child has at least 
one free action daily. This can be done by instructing the little 
one to go to the closet at the same hour every day, and to 
devote the whole time there to emptying the bowel. The pal- 
liative treatment is, to a certain extent, routine, and consists 
principally in the local application of astringents, or the injec- 
tion of the same into the prolapsed gut, which should be imme- 
diately returned. The daily injection of cold water into the 
bowel just previous to the patient's going to stool acts ad- 
mirably. The astringents recommended for the cure of pro- 
lapsus are many in number. Some of those that have stood the 
test of time are : tincture of iron, tannin, alum, sulphate of and 
chloride of zinc, etc. We have been in the habit of using a 



48 



DISEASES OF THE RECTUM AND ANUS. 



solution composed of pulverized alum, two drachms to the pint 
of water, with which the protruded mass was washed off before 
it was returned within the anus, and have been much pleased 
with the results. A decoction of black-oak bark acts equally 
well. When mild remedies fail to give relief, Allingham* rec- 
ommends the application of nitric acid. On the other hand, 
Mathews f deprecates its use in strong terms, and reports a case 
in which a bad result followed its use. In our experience the 
application of nitric acid has resulted in a cure in nearly every 
case where we have used it. It is never employed except in 
the treatment of prolapsus in children, when it is necessary to 
grease the surrounding parts with vaselin to protect them, and, 





Fig. 22.— Prolapsus Ani Truss. 



Fig. 23— Rectal Plug. 



further, to neutralize any excess of the acid with common soda. 
Kelsey % claims to be the first to cure prolapsus by the injection 
of carbolic acid into the protruded mass, and in the same manner 
as for the cure of hemorrhoids. The subcutaneous injection of 
ergotine into the perineum and immediate neighborhood of the 
anus has been highly recommended. We have had no experi- 
ence with the injection method ; consequently, we can neither 
decry nor commend it. In concluding these remarks on the 
palliative treatment, we desire to recommend rectal plugs (see 
figures), which are made in various sizes, to keep the bowel 
from protruding. The rectal plug consists of an oval knob of 
vulcanite with a slender shank, around which the sphincter COn- 



Diseases <>f the Rectum, p. 181. 



t Mathews, p. 480. 



X Kelsey, p. 218. 



PROLAPSE OF THE RECTUM. 



49 



tracts when it is introduced into the arms. We are indebted to 
Mr. Ball, of Dublin, for this ingenious device, which he has 
found to be of great service. It was invented by one of his 
patients. (See Fig. 23.) 

Operative Treatment. — When palliative measures have 
failed, it will be time to direct attention to operative procedure 
for the cure of this disease. It is pleasing to know that in this 
way relief can be given in nearly all cases. We shall not at- 
tempt to describe all the operations 
devised for the cure of prolapse, but 
will give briefly those that appear 
preferable. The cure of this condi- 
tion involves several objects, viz.: — 

1. To cause adhesion of the 
coats of the rectum. 

2. To remove redundant tissue. 

3. To reduce the size of the 
anal orifice. 

We place at the head of opera- 
tive procedures the actual cautery, 
which has been brought prominently 
before the profession by one of our 
American surgeons, Van Buren.* 
It has been sanctioned by Cripps 
and many other authors on rectal 
diseases, and is used as follows : 
The bowel having been thoroughly 

opened on the previous day, place the patient on the table 
in the Sims position, anesthetize him, and reduce the pro- 
lapse ; introduce a speculum which will separate the parts 
amply, and with the Paquelin therm o-cautery (narrow point) 
make a number of parallel lines an inch apart, beginning three 
inches (7.62 centimetres) above and terminating at the outer 
margin of the anus. (See Case II.) These lines are to be made 




Fig. 24. — Kelley Pad used in Opera- 
tions about the Rectum. 



* Van Buren, Diseases of the Rectum and Anus, p. 81. D. Appleton & Co. 

4 



50 DISEASES OF THE RECTUM AND ANUS. 

deeper and nearer together, if the severity of the case demand 
it. In this way we get the full effect of the cautery in pro- 
ducing rectal cicatrices. We have followed this plan in treating 
many cases of prolapse, some of which were very severe, and 
we have found it eminently satisfactory ; though, in a few cases, 
we had to repeat it two or three times, but finally obtained a 
cure. In mild or severe forms of prolapse, elliptical portions 
of the mucous membrane may be removed with the Gant clamp, 
scissors, and cautery, or the edges sutured together with carbo- 
lized catgut before the clamp is removed, llemoval of the pro- 
truded mass may be done with the clamp and cautery and elastic 
ligature ecraseur, or by the knife, the last being preferable in 
the larger proportion of cases where removal of the entire cir- 
cumference of the bowel is desirable. Such men as Allingham* 
and Cripps do not look upon excision with much favor. Some 
objections which suggest themselves are the danger of strictures 
following the operation, as well as the danger of Avounding the 
small intestine during the operation, should a hernia be present. 
While we cannot commend the operation of excision as one to 
be resorted to in the majority of cases of prolapse, we must admit 
that it is certainly of great value in some cases, and deserves 
to be mentioned in this connection. Believing the prolapsed 
condition to be due to an abnormally lengthened mesentery in 
severe cases, Allingham, Jr., has devised an operation for its 
cure, which is done by incising the abdominal wall on the left 
side about the outer third of Poupart's ligament; the rectum 
is then seized and drawn up, the mesentery sutured to the 
abdominal wall, and the wound closed. The object to be 
hoped for is to produce a firm adhesion so that the upper 
part of the rectum will be prevented from being intussus- 
cepted into the lower. We had the pleasure of witnessing this 
operation by Dr. Allingham while in London, and desire to say 
that we were favorably impressed with it, though, as yet, we 
have not had an opportunity of performing it. Dr. F. Lang, of 

* Allingham on Diseases of the Rectum, p. 187. 



PROLAPSE OF THE RECTUM. 51 

New York, devised an operation whereby he hopes to cure the 
prolapse by reduction in the calibre of the bowel as well as by 
the narrowing of the muscular ring. Yernenil. of Paris, en- 
deavors to overcome the prolapsed condition by raising the 
bowel and attaching it in the region of the coccyx. Both 
of these operations have their good points, but space forbids 
their further discussion in this work. 

ILLUSTRATIVE CASES. 
Case I. — Prolapsus due to Summer Diarrhea. 

A little girl. 2 years old. was brought to the dispensary to be treated 
for piles. Her mother said that the child had been suffering from summer 
complaint for three weeks and that the stools were frequent and caused 
much pain and straining : while on the chamber half an hour before, the 
piles came down. I placed the child across my knees, tlexed the limbs, 
and a tumor the size of a hen's egg (Fig. 20) presented itself just without 
the anus. The tumor was soft, smooth, and globular in shape, with a 
slit in the centre, and was of equal size on each side of the anus. The 
case proved to be a typical case of prolapse of the mucous membrane. 
The sphincter was relaxed, and every time the tumor was returned within 
the bowel it would immediately re-appear. 

Treatment. — Chloroform was administered and the tumor reduced; 
then the cautery-point was introduced up the bowel for two inches (5.08 
centimetres) and then brought down and outward. This was done a 
number of times, until there were a number of parallel lines about half 
an inch (1.3 centimetres) apart. Apiece of gauze smeared over with 
vaselin was placed in the bowel to keep the rectal walls separated. 
The buttocks were then strapped tightly together with adhesive plaster 
to support the anus during straining. An opiate was given to tie up the 
bowels and the child sent home. Two days afterward the straps were 
removed and a good action followed ; then they were replaced and kept 
on for four weeks, when she was discharged. Three months later I saw 
her again. She had been perfectly well ever since the operation. 

Case II. — Extensive Prolapsus of all the Rectal Coats. 

Dr. Pollard, of Braymer. Mo., came to me to have an operation 
performed for prolapsus of the rectum and gave the following history : 
Age 38 ; country practitioner ; general health good except that he suffered 
more or less from constipation and headache. He seldom had actions 
more than twice a week, and then thev were attended with violent strain- 



52 DISEASES OF THE RECTUM AND ANUS. 

ing and protrusion of the bowel. Sometimes only the mucous membrane 
would be everted ; at other Limes all of the rectal coats would come down 
for several inches, and, when not promptly returned, would swell up and 
were very difficult to reduce. 

Treatment. — He was anesthetized and the cautery applied deeply 
into the mucous membrane after Van Buren's method. It was then 
pressed deep down into the external sphincter in three different places, 
at equal distances apart, to insure contraction. The bowels were tied up 
for a week and the diet restricted to milk and soft-boiled eggs. On the 
seventh day, after taking a Seidlitz powder, he had a copious movement ; 
the bed-pan was used and he remained in a recumbent position. The 
rectum was irrigated and balsam of Peru applied to the mucous mem- 
brane. Ten days from the time he entered the hospital he returned home 
and, one week later, he was performing his usual duties. He called at 
my office a few months ago and said that the rectum had not troubled 
him in the least since the operation, more than two years ago. 

Case III. — Extensive Prolapsus. 

A lady came to be treated for extensive prolapsus. She had been 
operated on twice before by Van Buren's method. 

Operation. — It was decided to excise the redundant tissue, which 
was done after the following manner : An incision was made around the 
anus at the muco-cutaneous junction, and the mucous membrane dissected 
up for two inches (5.08 centimetres). It was then pulled down, cut off, 
and the upper portion brought down and attached to the skin by catgut 
sutures. Antiseptic dressings were applied, and union was complete 
within ten days without a drop of pus. At this time she was discharged 
with instructions to keep her bowels open and to report at mj^ office if 
the bowel came down again. One year afterward I met her and she in- 
formed me that she was well and that she had given birth to a fine boy 
since the operation. 

Case IV. — Dwarfed Child Suffering from Prolapsus. 

Eighteen months ago I was called to see a dwarfed child who had 
suffered from the time he was 6 weeks old with obstinate constipation 
and extensive prolapse of the rectal coats, which the father thought 
were the cause of the arrested development. He is 14 years old, weighs 
38 pounds, and measures thirty-two inches (81.28 centimetres) in height. 
(See Fig. 25.) During the past eleven years he did not gain one ounce 
in weight nor one inch (2.54 centimetres) in height. Another interesting 
feature in this case is that he has an angioma between the thumb and 
forefinger of the right hand. This the family physician lanced for an 



PROLAPSE OF THE RECTUM. 



53 



abscess and came near losing the patient from hemorrhnge. This lad 
was treated by the cautery method and the prolapsus was cured. I cite 
this case merety because it is a unique one. 

Six months after the above notes were made I saw the child again, 




Fig. 25. — Dwarfed Child Suffering from Extensive Prolapse of the Rectum. 



and decided to give the desiccated thyroid gland a trial. The improve- 
ment in his general appearance since that time has been marked, indeed. 
His father tells me that he has grown five inches (12. T centimetres) in 
lieight. His countenance has changed entirely, his speech has improved, 
and he shows considerable mental development. I have, through the 
father's kindness, a late picture of the bo} T which I scarcely recognized 
at first sight. The dose given in this case was two grains every four to 
six hours. 



CHAPTER VII. 

POLYPI AND OTHER NON-MALIGNANT GROWTHS. 

Non-malignant growths found in the rectum will prove, 
in a large majority of cases, to he polypi of some variety. They 
may he single or multiple ; they are found more frequently in 
childhood than in adult life. Their usual site is at the upper 
portion of the internal sphincter. Polypi have been mistaken 
for hemorrhoidal tumors in not a few instances. This mistake 
will not occur, however, when a careful examina f ion is made ; 
the polypus can be distinguished by its pyriform shape, long 
pedicle, florid-red color, and soft, delicate, elastic feel. For a 
thorough and extensive classification of non-malignant growths 
we would respectfully refer the reader to Leichen stern's classifi- 
cation,* which we think an admirable one. It is not our pur- 
pose to enter deeply into this subject, but to refer to the more 
common varieties of polypi which one might be expected to 
treat in the practice of rectal surgery. Polypi differ much both 
in appearance and feeling. This is accounted for by the dif- 
ferent tissues entering into their formation. If they are com- 
posed of glandular substance they are soft; while, on the other 
hand, if they are composed of fibrous tissue they are firm. 
Again, they may vary in size from that of a pea to that of a 
small lemon. In nearly all cases they will prove to be either 
fibrous or adenoid in character, for these two varieties constitute 
by far the larger percentage of rectal polypi. The pedicle, of a 
polypus may vary in length from one to three inches (2.54 to 7.6 
centimetres). We have seen one protrude two inches (5 centi- 
metres) below the anus. The pedicle is composed of mucous 
membrane ; and in some cases in the submucous tissues on the 
interior of the pedicle are to be found the vessels which give the 
blood-supply to the base of the tumor. 

* Ziemssen'e Cyclopedia, vol. vii, p. 634. 

(•54) 



POLYPI AND OTHER NON-MALIGNANT GROWTHS. 



55 



Adenoid, or Soft, Polypi. 

This variety is not uncommon. Soft polypi (Fig. 26) form 
generally in early life, and appear to be made up of an exag- 
gerated development of columnar epithelium ; in other words, 
the mass is made up of an enlargement of the follicles and the 
tissues of the normal mucous membrane. The pedicle is long 
and narrow and the base is small with a florid appearance, and 
when protruded from the anus after stool looks very much like 
a strawberry. In exceptional cases soft polypi may be due to 
dilatation of the glandular follicles. As a rule they are single, 
but occasionally they have been observed in great numbers. 

Symptoms. — The symptoms of non-malignant growths, 




Fig. 26.— Adenoid (Soft) Polypus, 



while not always characteristic, Avill often be of much assistance 
in making a diagnosis. Patients afflicted by polypus and other 
non-malignant growths seldom complain of pain. The first 
thing to attract their attention will be a slight bloody discharge 
after defecation. The bleeding may be slight, or, as we have 
seen, sufficient to weaken a child until he could scarcely stand 
alone. Hemorrhoids in the rectum of a child should at once 
lead us to suspect the presence of a polypus. Not infrequently 
the polypus acts as a foreign body and induces diarrhea or a 
discharge of mucus. The mother, in reciting the history of the 
case, will probably say, "Something comes down when the 
bowels move." This symptom is liable to lead one to suspect 



56 



DISEASES OF THE RECTUM AND ANUS. 



prolapsus. The differentiation, however, can be made by intro- 
ducing the finger into the rectum and passing it around the 
apex of the pedicle. The same holds good in reference to hem- 
orrhoids ; they have no pedicle, but are globular tumors. 

Treatment — The treatment of polypi in children is simple 
and always effectual. The proper treatment is to remove the 
polypus with the clamp and cautery (see Fig. 27) ; or, by placing 
a ligature around the pedicle at its attachment, that portion 
external to the ligature is cut off; or, after twisting it, it is 




Fig. 27. — Removal of Polypus High up with the Author's Clamp. 

snipped off with the scissors and some astringent is placed on 
the stump. The palliative treatment deserves slight mention in 
the treatment of polypi ; it consists in the application of astrin- 
gents as used for prolapsus. Astringents should never be 
resorted to except when consent to an operation cannot be 
obtained. 

Fibrous, or Hard, Polypi. 

The hard, or fibrous, polypi (see Fig. 28) occur in adults, 
and are more common in the rectum than those just described. 



POLYPI AND OTHER NON-MALIGNANT GROWTHS. 



57 



They appear to be formed from an increased growth in the 
fibro-cellular tissue beneath the mucous membrane, and covered 
by the normal membrane. The surface of the polypus may be 
smooth or irregular, being dependent on the shape of the sub- 
mucous enlargement, which protrudes farther and farther into 
the bowel, until a pedunculated tumor is produced, over which 
the mucous membrane forms a covering. This variety of 
polypus is pear-shaped, and the pedicle is more or less elon- 
gated and thickened at times. It may be soft and flabby, 
though it is more frequently tough, firm, and reddish when 
incised. Fibrous, or hard, polypi vary in size from that of a 
small hazel-nut to that of a walnut, and in exceptional cases 




fa 



<ig&i 




Fig. 28.— Fibrous (Hard) Polypus. 



may be much larger. The attachment of this variety is usually 
somewhat higher than the adenoid variety, or else the pedicle 
is shorter, for we have experienced more difficulty in placing a 
ligature around them. 

Symptoms. — When lodged in the bowel, it causes a sensa- 
tion of uneasiness as if a foreign body or a lump of fecal matter 
should be discharged. Not infrequently it acts as an irritant, 
causing ulceration and a discharge of pus and mucus, inducing 
a spasmodic condition of the sphincter which becomes quite 
painful. When the pedicle gets long, the tumor protrudes 
during defecation, and has to be replaced when the act is com- 
pleted. As a result, the polypus becomes ulcerated and bleed- 



58 



DISEASES OF THE RECTUM AND ANUS. 



ing accompanies the protrusion. The patient usually attributes 
these symptoms to piles. 

Treatment. — The treatment is similar to that of the ade- 
noid variety. All that is required is the ligation and excision 
of the pedicle ; or, if you prefer, it may be left there to slough 
off. Some authors prefer the ecraseur. In case the pedicle is 
short, or the attachment so high that you are unable to ligate it, 
catch the polypus with a pair of strong forceps and twist it off 




Fig. 29.— Pen Sketch of Fibromata from a Photograph of Case taken at the 
Author's Clinic by Mr. Joseph Lichtenberg. 

and apply the actual cautery or an astringent at the point of 
attachment. 

Disseminated Polypi. 

In reference to this variety Cripps* says: "Considerable 
areas of the mucous membrane of both the rectum and colon may 
be thickly studded with these polypoid growths." He has only 
seen three cases of this variety, and, after searching through the 
London museums, concludes that they are of rare occurrence. 
He further speaks of dermoid and cystic polypi, but they are so 
rare that we will onlv mention them. 



* Cripps, Disease of the Rectum and Anus. Second edition, p. 289. 



POLYPI AND OTHER NON-MALIGNANT GROWTHS. 59 

ILLUSTRATIVE CASES. 
Case V. — Large Fibrous Polypus of Several Years' Standing. 
"We were requested to examine a banker from a neighboring State. 
His family physician gave the following history of the case : The patient 
had a pile that had been coming down for several years every time his 
bowels would move ; it would bleed at times, but until recently he could 
easily replace it. Xow it was so large that it was exceedingly difficult to 
return. Of late there had been frequent discharges of mucus which irri- 
tated the skin about the anus, causing considerable pruritus. He was 
unable to sleep and to keep his mind on his business, and was very anx- 
ious to be cured. He was placed on the table and a digital examination 
made ; the finger easily passed the tumor, and above it was found 
attached b} T a pedicle the size of one's little finger. The doctor and the 
patient were much surprised when informed that there were no piles, but 
a polypus which could be speedily removed. The patient was anesthe- 
tized, placed in the lithotomy position, the sphincters divulsed, the pohr- 
pus pulled down by catch-forceps, and the pedicle ligated with strong 
silk at its junction with the mucous membrane. With a pair of scissors 
the pedicle was severed about one-fourth of an inch (6.3 millimetres) ex- 
ternal to the ligature, the rectum was irrigated, and the patient put to 
bed. On the fifth da} T the patient returned to his home and had no 
further trouble with his rectum. 

Case YI. — Adenoid Polypi. 
A lad} r came to us, aged 40, to be treated for rectal disease. Ex- 
amination revealed the presence of two small adenoid polypi about an 
inch (2.54 centimetres) in length, attached to the right wall of the rectum 
at the upper margin of the internal sphincter. They were promptly 
clamped, excised, and cauterized, and the patient recovered perfecthv 
within ten days. 

Villous Tumors of the Rectum. 

Villous tumors are seldom met with in the rectum, only 
eight cases having been seen at St. Mark's Hospital, London, 
in fifteen years. They seem to be the dividing line between 
benign and malignant growths ; often they resemble the latter, 
but are distinguished from them by their growing as free tumors 
into the bowel and by their short and broad base. Van Buren 
says that when a tumor lias a pedicle he doubts its malignancy. 
In structure they resemble the adenoid polypi and have a sim- 



60 DISEASES OF THE RECTUM AND ANUS. 

ilar appearance to villous growths of the bladder. They are 
considered benign by most authors, though they have recurred 

after removal. 

Symptoms. — The symptoms of villous tumors are similar 
to those of polypi, but the hemorrhages are probably more 
severe. They are rarely, if ever, met with in children. Their 
growth is gradual and they may become quite large. We re- 
member one case where the tumor was as large as a goose's egg. 

Treatment. — This consists in complete extirpation. With 
the patient in the lithotomy position and the sphincter stretched, 
the tumor is seized with a pair of pile-forceps and drawn down. 
Then the operator, with a blunt needle, should transfix the base 
of the tumor with a double ligature, cut this and tie both lobes 
of the pedicle, and cut off the tumor when the pedicle is long- 
en ough. If it has a very broad base it may have to be ligatured 
in several places similar to Bodenhamer's treatment for hemor- 
rhoids ; only the strongest silk should be used. In case consent 
to an operation cannot be obtained the tumors sometimes can 
be destroyed with the actual cautery or by the injection of 
astringents such as tannin, burnt alum, nitric acid, etc., into 
the tumor. 

Anal Papillomata. 

These growths resemble warts on other parts of the body. 
They originate in the papillary layer of the skin about the 
margin of the anus. They are generally multiple, of a dull-red 
color, fragile in texture, easily broken off, and bleed from the 
slightest irritation. In exceptional cases they are more firm. 
They are usually caused by discharges of pus from the rectum 
or a leucorrheal discharge. While papillomata are general in 
character, they are, as a rule, caused by acrid discharges. They 
are usually to be seen in patches, attached by small pedicles, 
while the extremity of the tumors bifurcate; and when there 
are a great number of them, they intermingle and form a large, 
fiat tumor attached by numerous little pedicles that are moist 
and have a disagreeable odor. 



POLYPI AND OTHER NON-MALIGNANT GROWTHS. 61 

Symptoms. — They may occur at any age and may vary 
from a single wart to a tumor surrounding the entire anus and 
extending upon the buttocks. The patient has pain during 
defecation ; and when the papillomata become irritated, each 
passage is accompanied by frequent hemorrhages. 

Diagnosis. — The diagnosis is usually not difficult, but 
papillomata must be differentiated from syphilitic condylomata, 
the latter arising from the mucous membrane, while the former 
arise from the integument. The papillomata may be present 
with the condylomata, being caused by the secretions of the 
latter. 

Treatment. — When large, warty growths, they may be cut off 
with scissors and their points of attachment cauterized. When 
small they can be made to shrink up by the use of powdered 
alum, zinc, tannin, and iron. Strict cleanliness must be ob- 
served ; and, if any cutaneous tags are present, they should be 
snipped off. Any disordered condition of the rectum, which 
might keep up a discharge, should be sought for and corrected. 



CHAPTER VIII. 
SYFHILITIC AFFECTIONS. 

Syphilis may appear about the rectum or the anus in a 
variety of forms. It may manifest itself in different stages. Both 
chancres and chancroids have been seen in this region. They 
are seldom seen in the male unless he has been guilty of hav- 
ing unnatural intercourse (sodomy). Females are more liable 
to have them, owing to the close proximity of the rectum and 
the vagina. The chancroid in the female is of common occur- 
rence, especially among prostitutes. When present they are 
usually multiple and situated at the anal margin, though they 
are sometimes as high as the upper part of the internal sphinc- 
ter. True chancre is of rare occurrence, and is differentiated 
from chancroid by its hard edge, indurated base, etc. 

Syphilitic Condylomata. 

Syphilitic condylomata (see Plate V) are of common occur- 
rence and resemble the warty growths, previously described, 
which are considered non-malignant. They vary in size from a 
small patch the size of a dime to that of a half-dollar or even 
larger. They develop from the simple syphilitic papule as a 
result of heat and moisture. They are raised above the skin 
and give off a foul odor. They may be smooth or nodulated, 
and a number of small patches may fuse, making one quite large 
one. When not treated early they irritate the skin, and the 
buttocks become ulcerated and bleed freely. 

Gummatous Deposits. 

Gummatous deposits are occasionally met with in the rec- 
tum. They usually precede ulceration and are followed by 
stricture, which will be fully dealt with in another chapter. 
The ulceration caused from a degenerate gumma is usually 
(62) 




PLATE V- SYPHILITIC CONDYLOMATA. 



BurkB MCFEtridgeCaLithfTHla. 



SYPHILITIC AFFECTIONS. 63 

deep and spreads high up in the rectum and, in rare cases, to 
the colon. This induces hemorrhage, tenesmus, and diarrheal 
discharges, and, when a stricture is present, constipation. Gum- 
matous deposits sometimes form in the tissues surrounding the 
rectum, which may cause obstruction. Specific ulceration will 
be considered more fully in the chapter on ulceration. 

Congenital Syphilis. 

Mucous patches have been noticed frequently in children 
who have syphilitic parents. We remember a family who had 
three children, all afflicted this way. 

Treatment of Syphilitic Affections. — The treatment of syph- 
ilitic affections of the rectum and that of the anus are similar 
in many respects to that employed in its treatment elsewhere. 
Cleanliness must be strictly observed. If a chancre, a chan- 
croid, or mucous patch is present, it must be cleansed two or 
three times daily with carbolized water or bichloride (1 to 2000); 
after which some good dusting-powder will be serviceable, — as 
iodoform, calomel, subiodide of bismuth, etc. The bowels should 
act daily, and a general syphilitic treatment prescribed. If there 
is any tendency toward the ulcerated areas' spreading, the edges 
should be cauterized with the actual cautery, nitric acid, or 
carbolic acid. Should the ulcer become chronic, incise it, or 
thoroughly divulse the sphincter. As a constitutional remedy 
the world-renowned blue pill, night and morning, will be of 
great value. 

In the treatment of condylomata Cripps recommends that 
the parts be thoroughly cleansed and dusted over with the 
following powder : — 

R Hydrargyri cliloridi mite, . . gr. xx ( 1.39 grammes). 

Iodoform], ..... gr. xxx ( 1.95 grammes). 

Zinci oxidi, 5j (4.00 grammes). 

Pulvis amyli, ^ss (15.00 grammes). 

M. Sig. : To be well mixed. 

Simple dusting-powders, — like calomel, zinc, lead, and tannic 



64 DISEASES OF THE RECTUM AND ANUS. 

acid, — together with the internal administration of mercury, 
have always brought about the desired result in our own 
practice. 

For gummatous deposits we are in the habit of prescribing 
the well-known mixed treatment, or the iodide of potassium 
alone in large doses. Beginning with 10 drops three times 
daily, it is pushed until the full physiological effect is obtained. 



CHAPTER IX. 
PROCTITIS AND PERIPROCTITIS. 

Inflammation of the rectum is not an uncommon affection 
and not infrequently results in the production of an abscess or 
a fistula. There are several varieties, yet the symptoms are 
similar in many respects. I will now enumerate the recognized 
varieties of proctitis : — 

1. Acute. 3. Dysenteric. 

2. Chronic. 4. Gonorrheal. 

5. Diphtheritic. 

Acute and Chronic Proctitis. 
The acute and chronic varieties of proctitis will be treated 
under one heading, for they are similar in everything ; the only 
difference is that in the chronic form the symptoms have become 
modified and there is less pain and tenderness. Children are 
subject to the acute and older persons to the chronic forms of 
proctitis ; in the former, because of frequent intestinal disturb- 
ances ; and in the latter, frequently as a result of fecal accumu- 
lations. An attack of inflammation may be brought on by 
pressure from impacted feces, exposure to cold, or the accidental 
introduction of foreign bodies into the rectum. We have seen 
it follow in subjects where a syringe had been carelessly intro- 
duced. Hard, indigestible substances in the feces which scratch 
the rectum — as fish-bones, pins, or grains of parched corn — are 
sufficient to start up an inflammatory process. Strong purga- 
tives and large doses of arsenic or corrosive sublimate, irritating 
discharges coming from above, and intussusception have all 
been known to set up an inflammation. 

(65) 



66 DISEASES OF THE RECTUM AND ANUS. 

Synqrfoms. — The symptoms are different in a given number 
of cases, dependent on the duration, kind, and violence of the 
attack. The following are some of the more common symptoms 
subject to the above conditions : — 

1. Severe* tenesmus and sense of weight in the rectum. 

2. Sensations of weight and fullness. 

3. Frequent discharges of small quantities of blood, mucus, 
or pus. 

4. Frequent spasmodic and unsuccessful attempts to 
evacuate the bowels. 

5. A desire to micturate often, though retention sometimes 
occurs. 

6. Constant straining, causing the mucous membrane to 
protrude. 

7. When an ulcer is present an abscess may form and 
terminate in a fistula. 

8. In general, any symptom present in inflammation of the 
intestine at any point may be found in proctitis in a modified 
form, such as radiating and reflected pains, and tenderness on 
pressure, etc. A simple attack will not last longer than eight 
or ten days, while the chronic form may last indefinitely, de- 
pending upon the cause and its removal. When the inflamma- 
tion lasts only a few days there will be no appreciable change 
of the bowel except where ulceration occurs. In cases of long 
standing the mucous membrane becomes thickened and in- 
durated and loses its sensibility to a greater or less degree, so 
that a considerable amount of feces may collect before there 
is a natural feeling to evacuate the bowel. Ulceration will be 
present in a goodly number of cases of long standing. 

Dysenteric Proctitis. 

In dysentery the lower bowel is often affected, especially 
in the tropical form, the symptoms being much the same as in 
the acute and the chronic forms, except that they are more 
general. 



proctitis and periproctitis. 67 

Gonorrheal Proctitis. ' 

This affliction is of rare occurrence and is found more fre- 
quently in the female than in the male, owing to the close 
proximity of the genitals. It is caused by direct contact of the 
mucous membrane with the virus, as a result of carelessness and 
uncleanliness or to unnatural intercourse. French surgeons 
report many cases due to the latter. It is not a difficult thing 
for the discharge to pass from the vagina to the anus and come 
in contact with the mucous membrane during the act of defe- 
cation. 

Symptoms. — There is a free discharge of white, purulent 
matter from the rectum ; the rectum feels hot and swollen, and 
the pain is of an itching or burning character and is inter- 
mittent. The margins of the anus become chafed and the 
sphincter becomes irritable. Patients are frequently awakened 
by the spasmodic contraction of the sphincter and with a desire 
to empty the bowel. Gonorrheal proctitis is of short duration 
and can be differentiated by a careful study of the symptoms 
and the existence of a previous urethral inflammation. The 
discharge is more abundant and contains more pus than any 
other variety of inflammation of the rectum. By the aid of the 
microscope a positive diagnosis can be made. 

Diphtheritic Proctitis. 

The rectum, like the other portions of the alimentary tube, 
may be invaded by the ravages of diphtheria ; it is of very rare 
occurrence, however. When it does occur the members of the 
family should be instructed to use the same closet with great 
caution. 

Prognosis. — As a rule, inflammation of the rectum will not 
prove fatal or even serious except in cases where the cause can- 
not be located and removed. On the other hand, when inflam- 
mation is due to a simple cold, impacted feces, injuries, or for- 
eign bodies in the rectum, a cure will follow the removal of the 



b'8 DISEASES OF THE RECTUM AND ANUS. 

irritation. The prognosis is less favorable in those cases com- 
plicated by fistula and ulceration. 

Treatment. — The principles that should guide us in the 
treatment of proctitis are several, and in the order of their im- 
portance are as follow : — 

1. Remove at the earliest opportunity the source of irrita- 
tion. 

2. Harsh and indigestible foods are to be discarded, and 
milk, soft-boiled eggs, soups, beef-juice, and albuminous foods 
substituted. 

3. Clear the bowel of any scybala that might be present 
by injections, Epsom salts, Seidlitz powders, and mineral waters. 

4. Insist on absolute rest in bed. 

5. In mild cases cold applied to the hips and the anus or 
the injection of cold water into the rectum will be sufficient. 

6. In long-standing cases use frequent injections of astrin- 
gent solutions, such as alum, zinc, silver, lead, and the subli- 
mate. When due to thread-worms a few injections of lime or 
salt water in conjunction with santonine internally will destroy 
them. If the inflammation is due to gonorrheal virus, frequent 
injections of water, as hot as the patient can bear it, do well. 
In a general way the treatment consists in keeping the bowels 
open and in correcting any errors in diet. When there is any 
ulceration present it should be treated the same as ulceration 
in other cases or from other causes. 

Periproctitis (Ischio-Rectal Abscess). 

The rectum is surrounded by loose tissues which not in- 
frequently become inflamed from a variety of causes, and the 
inflammatory process may be either diffused or circumscribed, 
and, when not arrested, goes on to abscess formation. The pus 
burrows downward, forcing itself through the rectum, and is 
discharged with the feces or opens upon the surface of the 
body, thus making a fistula. Sometimes the inflammation starts 
within the rectum as a result of exposure to cold, an injury, or 



PROCTITIS AND PERIPROCTITIS 69 

from ulceration. Now and then we come across a case where 
the cause remains obscure. Again, those who have a tubercu- 
lar diathesis are frequent sufferers from periproctitis. This is 
demonstrated by the great number of them who have fistula. 
Periproctitis has been known to follow operations about the 
rectum where asepsis had not been closely observed. In such 
cases the inflammation will be ushered in by a chill, followed 
by pain and a decided rise in temperature. In very exceptional 
cases the inflammation may take on an erysipelatous or gangre- 
nous character, and must be radically dealt with at once, else 
it will prove fatal. 

Symptoms. — The symptoms of perirectal inflammation are 
similar in many respects to those of proctitis. In this disease 
they become more exaggerated, and there are more constitu- 
tional disturbances and all the symptoms of pus formation. 

Treatment of Periproctitis (Isci hio- Rectal Abscess). — First 
ferret out the cause and correct it ; then endeavor to reduce the 
inflammation by the application of cold, rest in bed, and the use 
of mild laxatives, etc. When fluctuation is present, absorption 
can hardly be expected to take place. It stands to reason that 
the sooner the pus is evacuated the better it will be for the 
patient, for it is likely to burrow through where an opening is 
not made, and terminate in a single fistula or multiple fistulas. 
Many of these patients can be saved much suffering by an early 
diagnosis of pus formation if an incision is made into the ab- 
scess and its cavity thoroughly cleansed with a boric-acid solu- 
tion and free drainage established. The cavity should always 
be packed loosely with some antiseptic gauze after being irri- 
gated daily with a sublimate solution one- to two- or three- 
thousandths. If the pain continue to be severe, keep on a 
poultice for two or three days after the abscess has been 
opened. Ordinarily, the abscess will point in the rectum or 
perineum. When in the former, it will invariably leave a fist- 
ula ; on the other hand, when in the perineum or at the side of 
the anus, it is termed a perineal or an ischio-rectal abscess, and, 



70 DISEASES OF THE RECTUM AND ANUS. 

when taken in hand early by the surgeon, the pus can be pre- 
vented from burrowing and forming fistulas and much suffer- 
ing avoided. Allingham treats these cases as follows: Under 
anesthesia, he incises the abscess from end to end in the direc- 
tion from the coccyx in the perineum. Secondary cavities are 
then broken up with the finger so that only one cavity remains. 
If there is any burrowing outward, an incision is made in the 
buttocks at right angles to the first, after which the cavity is 
irrigated and packed with cotton-wool soaked in carbolic oil 
one part in ten or twelve. This is left in a day or two, when 
the dressings are to be changed. Ordinarily, a drainage-tube 
will not be necessary, and patients soon recover without the risk 
of inconvenience, for the sphincters have not been touched. 

Marginal Abscess. 

When a collection of pus takes place at the muco-cutane- 
ous junction it constitutes a marginal abscess, about which the 
French have written so much, and it is the most simple form 
of abscess that we are called upon to treat about the rectum 
and the anus. The most frequent cause of this form of abscess 
is suppurating thrombotic piles that have not been incised and 
the clot turned out. Traumatism, exposure to cold, thread- 
worms, and ulceration may all be put down as causes ; in fact, 
almost anything that would cause an abscess in any other 
portion of the body might be the cause of one at the anal 
margin. 

Treatment, — From the time the patient begins suffering 
from that characteristic throbbing pain until you are permitted 
to incise the abscess, much relief can be had from the constant 
application of the ice-bag or of hot poultices over the seat of 
pain. The latter should be changed every half-hour to get the 
best effect. Just as soon as the circumstances permit, the 
abscess must be opened, curetted out, and drained. A prompt 
recovery will quickly follow. The finger should be passed into 
the rectum (or the vagina, in women) and pressure made out- 



PROCTITIS AND PERIPROCTITIS. 71 

ward. This makes the parts bulge outward, and the cut can be 
made more intelligently. 

Erysipelatous and Gangrenous 'Inflammation. 
The symptoms and treatment of these forms of inflamma- 
tion are much the same as similar conditions found in other 
parts of the body. In brief, the treatment consists in free 
incisions, frequent irrigations, and tonics. 



CHAPTER X. 

RECTAL AND ANAL FISTULAS. 

This chapter would very naturally follow the preceding 
one from the fact that rectal and anal fistulas are the sequels of 
inflammation of the rectum and of the tissues immediately sur- 
rounding it. Fistulas occurring about the rectum and anus 
have for hundreds of years been described under the name of 
" fistula in ano," and for this reason we shall designate them as 
such, although it would be more scientific and expressive, as 
far as the location of the disease is concerned, if those fistulas 
opening high up in the rectum were designated rectal and those 
opening just within the anal margin anal fistulas. Fistula in 
ano was accurately described by Hippocrates, Celsus, and many 
other ancient writers ; and the etiology as given by them, in a 
large measure, holds good to-day. From the time of the 
Christian era, or of Hippocrates, little was written about 
fistulas for several hundred years. The principal reason for 
this was that persons who had fistulas had an incurable disease, 
and, in the olden times, to have an incurable disease was to 
have a disgraceful one. Another reason why this disease was 
not seen and described more frequently was due to the fact that 
those who had it would not submit themselves to a visual and 
digital examination. In Hume's " History of England " he 
records the death of Henry V, King of England, in 1422. 
He says that the king was seized with a fistula, — a malady that 
the surgeons at that time had not the necessary skill to cure. 
Shakespeare has immortalized fistula in his play, "All's Well 
that Ends Well," written about 1606. Later, John Astruc, in 
his Latin thesis, translated into English in 1728, tells us that 
this disorder sunk almost into oblivion, and was scarce seen or 
heard of by the physicians until Louis XIV, of France, labored 
under it. Then the disease at once became fashionable, and a 
(72) 



RECTAL AND ANAL FISTULAS. 73 

vast multitude of cases suddenly appeared ; and, after the 
king's example, every one made a voluntary and open confes- 
sion of this once secret disorder. He further says that, in the 
reign of Tiberius Caesar, the disease first showed itself. No 
man in Rome ever complained of it until the emperor had been 
severely attacked by it. It is stated that Louis XIV paid 
Monsieur Felix and his various assistants, in American money, 
the enormous sum of seventy-three thousand five hundred 
dollars for the operation. 

There are some to-day who believe that this disease is 
incurable, and others that, if the fistula is healed and the dis- 
charge stopped, some internal organ will suffer from the pent- 
up matter. For these reasons many persons go through life, 
suffering great pain and annoyance, who have but a simple 
fistula that could be speedily and easily cured, and with very 
little pain at that, if they would only place themselves in the 
hands of a competent surgeon and be operated upon. Statistics 
show that fistula occurs more frequently than any other rectal 
disease, and that males are more often afflicted with it than 
females. At St. Mark's Hospital,* in London, very nearly one- 
third of the total number of all the cases treated in that remark- 
able institution suffered from fistula. This is hardly a fair com- 
parison of the relative frequency of this disease, because this 
hospital has a world-wide reputation for curing fistula ; and it 
is very natural that more persons afflicted with this complaint 
go there for treatment than those suffering from other rectal 
diseases. The proportion of fistula to other rectal diseases is 
always much greater in hospital and dispensary than in private 
practice. In private practice we have been called upon to treat 
both hemorrhoids and ulcerations (including fissures) more often 
than fistula, and we are of the opinion that the experience of 
many other American surgeons has been the same. A fistula 
in ano may be defined as a non-granulating sinus with two 
openings, — one ujjon the surface of the body near the anus and 

* Cooper and Edwards, Diseases of the Rectum and Anus, p. 4, 1892. 



74 DISEASES OF THE RECTUM AND ANUS. 

the other within the rectum; this would constitute a complete or 
typical fistula. There are several other varieties of fistula, each 
of which we will speak of in turn. Nearly all fistulas are the 
result of an abscess which has formed in the perirectal tissues 
and opens into the rectum or upon the surface ; and the sinus 
thus formed ordinarily will not heal of its own accord. Ab- 
scesses that produce fistula in ano will be found in one of the 
following locations : — 

1. Between the mucous and muscular coats of the rectum. 

2. Between the rectum and the levator ani muscle. 

3. Anywhere in the ischio-rectal fossa. 

4. Just beneath the skin near the anus. 

An abscess located in one of the above positions forms and 
bursts and the pus makes one or more outlets, depending upon 
the direction it has taken. The kind of fistula produced 
depends not only upon the direction taken by the pus in its 
endeavor to seek an outlet, but upon the number and location 
of the openings produced. We have the following recognized 
forms of rectal fistula : — 

1. Complete. 5. Complete external. 

2. Blind internal. 6. Horseshoe. 

3. Blind external. 7. Recto-vaginal. 

4. Complete internal. 8. Recto-vesical. 

9. Recto-uretkral. 

The last three varieties do not come under the classification 
of fistula as usually given because of their contact with other 
organs. 

Complete Fistula. 

When we speak of a fistula without designating any 
special variety we mean a complete fistula (see A, Fig. »30, and 
Plate VII), or one that has two openings, — one upon the sur- 
face of the body in the neighborhood of the anus and the other 
opening into the rectum. These openings vary as regard loca- 
tion. As a rule, the internal opening will be found about the 



RECTAL AND ANAL FISTULAS. 



75 



junction of the external and internal sphincters, though in not 
a few cases it will be found higher up. The external opening 
will ordinarily be found within an inch (2.54 centimetres) of 
the anus, and in many cases just opposite the internal opening. 
Again, the external opening may be quite a distance from the 
anus, and the sinus leading from the external to the internal 
opening may be very long and irregular. 




Fig. 30.-^1. Complete Fistula, B. Blind Internal Fistula. 



Blind Internal Fistula. 

This form of fistula (see B, Fig. 30) consists of a sinus 
that does not haA T e any external communication, but an internal 
opening into the rectum. While not so common as the com- 
plete variety, one who treats rectal disease as a specialty will 
meet many such cases and will find them, in many instances, 
very difficult to diagnose. 



76 



DISEASES OF THE RECTUM AND ANUS. 



Blind External Fistula. 
This variety (see A, Fig. 31) is formed from an abscess 
located in the subcutaneous tissues, the pus from which has 
found an outlet upon the surface and does not communicate 
with the rectum at all, though it burrows in that direction if 
not operated upon. This form of fistula is very rare, being seen 
less frequently than the blind internal variety. 




Fig. 31.— A. Blind External Fistula. B. Complete Internal Fistula. 

Complete Internal Fistula. 
This variety (see B, Fig. 31) is seldom met with. It con- 
sists of a sinus with two openings into the rectum, and is very 
difficult to diagnose, but easily cured when the tract is slit up. 

Complete External Fistula. 
This form (see A, Fig. 32) is also quite rare, and consists 
of a sinus with two openings, both of which are external to the 
rectum, — one situated just at the margin of the anus and the 
other at some point on the buttock. 



RECTAL AND ANAL FISTULAS. 



Recto- Vaginal Fistula. 



i i 



In this variety the sinus opens into both vagina and rec- 
tum (see B, Fig. 32). They are not uncommon, and when the 
opening between these two organs is not very small fecal 
matter will escape into the vagina. This condition is easy to 
diagnose. 




Fig. 32— .4. Complete External Fistula. B. Recto-Vaginal Fistula, 

Horseshoe Fistula. 

This form of fistula (see Fig. 33) gets its name from the 
fact that the fistulous sinus courses around the rectum from one 
side to the other, shaped to some extent like a horseshoe. There 
are one or more openings into the buttocks on both sides of the 
anus, communicating with each other and with the rectum 
usually by an opening into the posterior wall of the bowel, 



78 



DISEASES OF THE RECTUM AND ANUS. 



though in some cases there may be two or even more openings 
into the rectum. In a bad case of horseshoe fistula there may 
be multiple sinuses and openings. We remember one case 
where there were nine external openings, and the buttocks 
looked very much as if a load of buckshot had been emptied 
into them. 




Fig. 33.— Horseshoe Fistula. 



Recto- Vesical Fistula. 

This variety (see A, Fig. 34, and Plate VI) is one where 
there is a communication between the rectum and the bladder, 
as a result of an abscess discharging into both organs, and wind 
and feces may pass by the penis and the urine may empty into 
the rectum. A severe attack of cystitis usually occurs, which 
induces much suffering until the patient dies or an operation is 
required. The diagnostic point is the passing of urine and 
feces through unnatural channels. 




PLATEVL- TYPICAL CASE OF RECTO VESICAL FISTULA SHOWING 
RESULT OF EXTRAVASATION OF URINE INTO SCROTUM AND PENIS. 



EurkBM=FetridgECo.LithPnila. 



RECTAL AND ANAL FISTULAS. 



79 



Urinary, or Recto-Urethral, Fistula. 

These fistulas (see B, Fig. 34) are rare, indeed. In such 
cases the rectum communicates with the urethra at some point. 
Cripps has reported a very interesting case which healed spon- 
taneously. 

General Remarks on Fistula. 

Fistula is the sequel of an abscess, as a rule. Some claim 
that we may have a fistula in tuberculous patients without a 
distinct circumscribed cavity's being formed. We have never 




Fig. 34. — A. Recto-Vesical Fistula. B. Recto-Urethral Fistula. 

seen a case of this kind, but always find that an abscess had 
formed as a result of an ulceration or poisonous matter escaping 
into the deeper tissues, or from any of the many causes of ab- 
scesses mentioned in the previous chapter, such as inflamed 
piles, exposure to cold, injuries, thread-worms, etc. The abscess- 
cavity and sinus gradually become a fistulous sinus, because 
the feces constantly get into it and prevent healing. The spas- 
modic contraction of the sphincter also tends to delay it. Some- 
times a fistula will occur as a result of necrosis of the coccyx 
or sacrum. 



80 DISEASES OF THE RECTUM AND ANUS. 

Any person, irrespective of age, climate, or occupation, may 
have a fistula. Men are more subject to fistulas than women, and 
during middle life ; children rarely have them. We remember 
seeing only one case, — that of a child, 18 months old, that had 
thread-worms accompanied by an abscess which resulted in a 
fistula. The mental worry of persons who are aware that they 
are suffering from fistulas is very great until they are cured ; 
and yet many of these sufferers will endure much pain and 
annoyance for a long time before they will submit to a cutting 
operation. They will readily consent to anything except the 
use of the knife, — the right thing. 

SYMPTOMS. 

Ordinarily the patient will say that the discharge was pre- 
ceded by great pain, heat, swelling, and other symptoms which 
would likely accompany the formation of an abscess, and that 
the acute symptoms disappeared when the pus made its exit. 
A fistula once established, the following symptoms will be pres- 
ent : There will be a discharge from the external opening, which, 
in the majority of cases, will be found a little to one side of the 
anus. The discharge will be abundant, thick, and almost con- 
stant in a new fistula, while in an old one it will be very thin 
and watery. When the discharge is interrupted, it is well to 
suspect that there are other sinuses leading off from the main 
tract. The discharge is very annoying to the patient, for it 
keeps the linen soiled and the skin inflamed. Sometimes the 
opening is small or becomes closed, and the discharge ceases 
for a short time, leading the patient to believe that he is well. 
It will not be long, however, until there will be a renewal of 
pain and swelling, followed by a fresh discharge of pus through 
a new outlet. The pain in a fistula is slight when the ex- 
ternal opening is large, but will be very severe when it is 
small and will not allow the discharge a free and unimpeded 
exit. W r ind and feces may escape through it and give a foul 
odor to the discharge. 



RECTAL AND ANAL FISTULAS. 81 

DIAGNOSIS. 

The diagnosis of a complete fistula under ordinary circum- 
stances is not a difficult thing. Much more ingenuity will he 
required in locating the hlind internal and horseshoe varieties. 
It stands us in hand not only to locate the fistula, hut also 
to ascertain and locate the number and direction of any other 
sinuses that might communicate with the main one. In order 
to make a thorough examination it is necessary to have a 
firm table and a good light. Some prefer to place the patient 
in one position, some in another. The three favorite positions 
are : first, the Sims, with the patient on the affected side and 
the limbs flexed on the abdomen ; second, the genupectoral ; 
third, the lithotomy position. We favor the last, but do not 
use it exclusively. After the patient has been placed in position 
the buttocks should be separated and external openings should 
be searched for. When present, the opening will be found in 
the centre of a small depression, or, more frequently, in the 
centre of a small, elevated mass of granulations. Next, pass 
the finger about the anus and the immediate vicinity, and, 
by palpation, fistulous tracts in the subcutaneous tissues will 
be readily detected by their hard feel. This diagnostic point 
will prove valuable when searching for the blind internal va- 
riety. In case the external opening has been found, oil the 
finger well and pass it into the bowel. If an internal opening- 
exist it can be detected by its indurated and, in some cases, 
rough edges. Frequently the opening will be found just be- 
tween the internal and external sphincters. It is not uncom- 
mon, however, to find it much higher up. In case the internal 
opening cannot be located, milk should be injected through 
the external opening, and it wall force its way into the bowel 
through the internal opening, which can then be easily located. 
A probe should be used very cautiously. No force should be 
applied lest it be pushed through the main sinus into the soft 
tissues, where it can be passed in any direction, thus leading 
the examiner to believe that he has found a very extensive 



82 DISEASES OF THE RECTUM AND ANUS. 

fistula, when, in reality, it is a short and simple one. All 
ulcerated spots and inflamed pockets should be examined 
closely, for not infrequently there is hidden within the mouth 
a blind internal fistula. 

TREATMENT. 

Now and then a case is reported where a fistula has 
healed spontaneously. It is needless to say that such a one 
is an exception. Palliative measures, in most cases, are of little 
service ; they consist in keeping the bowels in proper condition, 
of applying stimulating applications to the sinus and keeping- 
it clean, together with medicines that will be likely to improve 
the patient's general condition. If the patient will consent to 
let you operate, do so at once. At the same time, take every 
precaution to let the patient lose very little blood, especially 
in anaemic or consumptive patients. Any other rectal disease 
present, such as piles, ulceration, stricture, etc., should be rem- 
edied during or preceding the operation, else it may cause fail- 
ure. Allingham says that we should never operate on a fistula 
that is from any cause acutely inflamed, on account of the like- 
lihood of fresh sinuses forming, for the areolar tissue breaks 
down very readily. He believes in making a free, dependent 
opening until the inflammation subsides ; then the operation 
may be completed. There are six recognized methods of oper- 
ating for fistula : — 

1. Dilatation. 4. Division by (a) the knife; 

2. Injection of astringent fluids. (6) Paquelin cautery-point. 

3. Ligation. 5. Excision. 

6. By fistulatome. 

A purgative should be given one or two days before the 
operation, and the rectum should be thoroughly emptied by an 
injection one hour previous to the same. The neighboring 
parts must be cleansed and shaved, if necessary. Then the 
operator can proceed to do the operation which is best suited to 
the case in hand. 



RECTAL AND ANAL FISTULAS. 83 

We wish to state, in this connection, that we never resort 
to any operations we have named, barring that of complete 
division, except in phthisical patients who can iii afford the loss 
of even a small quantity of blood, and in those unconquerable 
individuals who absolutely refuse to have the knife used. 

Dilatation. — This operation consists in keeping the mouth 
and all or part of the sinus dilated, that the pus may have a 
free exit, and granulations stimulated by lacerating it along its 
entire length with some rough instrument, or the direct appli- 
cation of some astringent, as zinc, silver nitrate, alum, and car- 
bolic acid. Allingham prefers the latter, and inserts a rubber 
drainage-tube into the sinus and gradually withdraws it as 
healing takes place. The dilatation may be made with instru- 
ments, sponge-tents, or anything which may bring about the 
desired result. This procedure scarcely deserves to be called an 
operation ; at the same time, we could not call it a palliative 
measure. 

Injection of Astringent Fluids. — Any of the ordinary 
astringents — zinc, iron, silver, carbolic acid, or ergot — will do, 
as well as any others, with possibly the exception of ergotine. 
They must be injected in and around the sinus. If, by any 
means, fecal matter can be kept out of the fistulous sinus during 
'the treatment, a very important point is gained. To do this we 
resort to the following plan : After the sinus has been cleansed 
with soap and water and followed by the peroxide of hydrogen, 
we take a probe threaded with a silk ligature, on the end of 
which is attached a small wad of cotton, and pass it through 
the external opening and into the rectum, when it is caught 
and drawn downward. At the same time the cotton is carried 
along the sinus until it can be felt just beneath the mucous 
membrane under the internal opening, the probe is detached, 
and the ligature left hanging inside the bowel. In this way all 
fecal communication is cut off. Then the injection is made and 
the needle withdrawn slowly as the fluid is forced out. An 
ordinary hypodermatic syringe can be used, if it has an extra 



84 



DISEASES OF THE RECTUM AND ANUS. 



needle with a blunt point about tliree inches (7.6 centimetres) in 
length or an extension-piece. The operation must be repeated 
several times. When healing takes place it is from within 

outward. When it reaches the surface of 
the body the cotton can be removed by 
jerking out the ligature in the bowel, 
after which a final injection should be 
made into tbe bowel at the seat of the 
internal opening, and the treatment is 
completed. W r e have cured a few cases 
in this way, and our patients have been 
very grateful, though in many the treat- 
ment proved a total failure. This method 
of treating fistula causes more pain and 
requires a longer time to effect a cure 
than does the more radical operation of 
division. 

Ligation. — To Allingham, Sr., and 
Prof. Dittel, of Vienna, belong the credit 
of bringing this method of operating on 
fistula before the profession. Neither of 
them, however, originated it, for an accu- 
rate description had been given it by 
Celsus. The operation consists in passing 
a ligature through the sinus and out at 
the anus. After the ligature is tied 
tightly, it constricts all intervening tissues 
and is allowed to cut its way out. The 
ligature can be introduced threaded on 
an ordinary probe which has an eye, or 
by means of Mr. Allingham 's ingenious 
instrument (see Fig. 35), by means of which it can be drawn 
from within the rectum to the outside. The ligature used may 
be ordinary silk or it may be elastic, the latter being preferable 
because it makes a uniform pressure. A piece of solid India 



Fig. 35.— Allingham'e Elastic 
Ligature Carrier. 



RECTAL AND ANAL FISTULAS. 85 

rubber from one-twelfth to one-eighth of an inch (2.2 to 3.2 
millimetres) in thickness is the most desirable, the ends of which 
can be secured by slipping a piece of lead with a slit in it over 
them, the lead being secured by the aid of strong forceps. The 
following are some of the advantages claimed for the ligature 
operation : — 

1. It does away with the knife. 

2. Can be done without an anesthetic. 

3. It is comparatively painless. 

4. It permits the patient to walk about in the fresh air. 

5. There is no bleeding. 

We will now enumerate some of the objections that have 
been raised against this operation : — 

1. It requires a longer time to effect a cure than does 
incision. 

2. Only the main sinus can be included ; -hence the oper- 
ation will be a failure when there are other sinuses leading off 
from the main one. 

3. The ligatures have been known to cut only part of the 
way out, thus requiring the knife to divide the remaining 
tissues. 

4. It is not suitable for operations on fistulas in general. 
As we take it, the field for ligature operation should be confined 
to persons who refuse to be operated upon by the knife and 
those who are anemic or have phthisis. This operation is 
especially adapted to the treatment of phthisical patients from 
the fact that they can take their usual amount of out-door 
exercise while the ligature is sloughing off with comparatively 
little annoyance, and, further, from the fact that they have not 
lost any blood. 

Division. — The patient should be anesthetized unless the 
fistula is a superficial one that can be divided easily, when this 
operation is selected. There will be considerable pain and the 
surgeon does not always know how extensive the operation may 
be before he gets through. Frequently there will be unsuspected 



8(i 



DISEASES OF THE RECTUM AND ANUS. 



sinuses that require incising, and they may lead far out into the 
buttocks. At least two assistants will be necessary, one to give 
the chloroform and the other to hold the buttocks well up out 
of the way ; and, if you have a third, so much the better, for he 
can handle the sponges and instruments. We shall first speak 
of operating on a simple or a complete fistula, which is done 
after the following manner (see Plate VII) : A groove director 
suitable to the size of the sinus is introduced into the outer and 




Fig. 36.— Gorget. 

through the inner opening into the rectum. It is then brought 
out at the anus by the index finger of the left hand, introduced 
into the rectum' for that purpose. Then with a strong, straight, 
or curved bistoury divide the entire bridge of tissue resting on 
the director. This should be done as nearly at a right angle to 
the sphincter as possible, and not in an oblique direction as 
some do, for incontinence is more apt to follow the latter. 
When the fistula is not a deep one the silver groove director is 




Fig. :>7.— Ailing-ham's Scissors and Groove Director. 

preferable, because it is more pliable. In cases of extensive 
fistula it is well to have a number of steel groove directors, of 
different lengths and sizes, that w 7 ill not bend, to use in oper- 
ations where the sinuses are long, indurated, and where the 
internal opening is situated so high up in the rectum that the 
distal end of the director cannot be brought out at the anus. 
In such cases a piece of soft wood, or a steel gorget (see Fig. 
30) one-half inch (12.7 millimetres) wide and eight inches 



-a 
Ir- 



3 






M 



CD 



CD 

-3 



> 

CD 



CD 

I 



CD 

cn 




RECTAL AND ANAL FISTULAS. 87 

(2 decimetres) long, is introduced into the rectum after the 
director is in proper position. The knife is then made to follow 
the director along the fistulous tract until its point enters the 
rectum and is pressed into the piece of wood. Both should then 
be drawn together, thus severing all the intervening tissues. 
Allingham's scissors and director are especially adapted for such 
cases. (See Figs. 37 and 38.) There is a knob on the under 
surface of the lower blade which is made to follow in the oval 
groove in the director, cutting the tissues from without inward. 



-m: 




M 



: : f ; y ' 

m jr 




One cannot be too careful in the selection of cutting instruments 
for operating on fistulas. They must be strong and of the very 
best metal, else they are liable to snap in two when they come 
in contact with a deep sinus made up of scar-tissue. We had 
the misfortune in one case to break the knife and the operation 
was delayed for a considerable time before we succeeded in find- 
ing the broken blade and removing it. Another and a better 
way when the sinus reaches high up the bowel, or when other 
sinuses are suspected, is to dissect slowly from below upward, 



88 DISEASES OF THE RECTUM AND ANUS. 

following the director until the end of the sinus is reached ; 
then any diverticula from the main sinus will not he overlooked. 
After complete division of all the tissues of a complete fistula, 
it is well to curette the entire tract or do as Mr. Salmon has 
recommended : make an incision along the entire bottom of the 
fistulous tract. This will insure healing from the bottom. 

Excision. — A few years ago Dr. Frederick Lange reported 
a. number of cases successfully treated by excision, and recom- 
mended this procedure. The operation for some reason has not 
become popular. It is done after the following manner : The 
entire sinus should be laid open in a manner similar to that of 
the operation for a complete fistula. Then all of the old fistu- 
lous sinus should be carefully dissected out and the entire sur- 
face dusted over with some antiseptic, the rough surfaces per- 
fectly adjusted with catgut sutures, and a dry dressing applied. 
If the operation is a success there will be very little need for 
after-dressings, since the wound will heal in a few days by first 
intention. In case it should not, it can be treated as after 
the ordinary operation. We have performed this operation a 
number of times, and have not been satisfied with it, for in 
all except a few cases we did not get healing of the entire 
wound by first intention ; and some of the operations were not 
only tedious, but difficult to do, owing to extensive cicatrices. 
The operation has proved eminently successful in cases where 
there were two or more external sinuses that communicate with 
each other and with the rectum. By dissecting out the sinus 
between the two external openings and bringing the edges 
together with catgut sutures, after the main one had been 
divided, a good result was obtained in every instance. The 
sinus between the two external openings healed by first inten- 
tion and the main one, leading into the rectum, by granulation. 

By Fwtulatome. — That distinguished Southern surgeon, 
Dr. Mathews, of Louisville,* has devised a very ingenious 
instrument, the "fistulatome" (see Fig. 39), which he recom- 

* Mathews. Diseases of Rectum and Anus. First edition, p. 211. 



RECTAL AND ANAL FISTULAS. 89 

mends in selected cases. As yet we have never used this 
instrument ; so can neither commend nor condemn it, from an 
experimental stand-point. We believe, however, that its sphere 
of usefulness is limited to those cases where extensive cutting is 
contra-indicated and to cases where patients cannot be per- 
suaded to have a better and more radical operation performed. 

Blind External Fistula. — In this variety there is no open- 
ing into the bowel. They are to be operated on just like the 



^fc 



Fig. 39.— Mathews's Fistulatome. 

complete variety, after an opening has been made into the 
rectum by forcing the director through it, thus making it 
complete. 

Blind Internal Fistula. — In this variety, after the sphincter 
has been divulsed, the speculum introduced, and the internal 
opening located, a director (see Fig. 40) or probe is passed into 
it and passed downward until it makes the skin bulge out; 




Fig. 40.— Author's Angular Groove Director for Blind Internal Fistula. 

then, with a bistoury, make an incision over the end of the 
director. It then slips through and you have a complete 
fistula, and all tissues on the director are divided. 

Complete External Fistula. — This variety is usually super- 
ficial, and can be divided without any anesthesia by introducing 
the director into one external opening and out at the other, and 
quickly severing the intervening tissues. 

Complete Internal Fistula. — The only difference in oper- 



90 DISEASES OF THE RECTUM AND ANUS. 

ating on this variety and the one just described is that the 
speculum is necessary that the openings may be located and 
the director introduced, after which the operation is performed 
as previously described. 

Horseshoe Fistula. — When two or more external openings 
appear upon the buttocks a thorough examination should be 
made to ascertain whether there be two distinct fistulas or if 
the two external openings communicate with each other and 
with the rectum by one sinus, constituting a horseshoe fistula. 
(See Figs. 33 and 41.) When the latter condition is found, it 
gives the surgeon a chance to display his ingenuity in doing the 
operation as it should be done, — namely, all the sinuses between 
the external openings should be laid open first, then made to 
communicate with the rectum by dividing the main sinus. (See 
Fig. 42.) In this way the sphincter is severed but once and 
there is little danger of incontinence's following the operation. 
On the other hand, if the director is passed into each of the 
outer openings, forced into the rectum, and the tissues divided 
once for each opening, the sphincter will be cut two or more 
times and the danger of incontinence is materially increased. 
Incontinence almost invariably follows when the sphincter has 
been divided three times. In exceptional cases, however, incon- 
tinence will follow in spite of every precaution. Knowing this 
to be a fact, we always mention to patients the possibility of 
this accident following the operation, though it is not likely to 
occur; then if, after this explanation, incontinence does occur, the 
patient will take part of the blame upon himself for submitting 
to the operation. On the other hand, if you do not caution 
him, and incontinence follows, he will never forgive you, and he 
is likely to refuse the payment of the bill and bring suit against 
you for malpractice. 

Recto-Vu(jin<<l Fistula. — The question is sometimes raised 
as to who should operate on this variety of fistula, — the rectal 
specialist or the gynecologist. So far as our practice is con- 
cerned, we have been in the habit of operating on all such 



RECTAL AND ANAL FISTULAS. 91 

cases coming to us for treatment, and we are willing to concede 
to our gynecological friends the same privilege. In the treat- 
ment of this form of fistula the principle of the operation is 
much the same as in other varieties. Some dissect out the 
fistulous tract and suture the edges together and endeavor to 
get union hy first intention ; others divide the sinus and allow 
it to heal hy granulation ; and still others prefer the elastic 
ligature. For a further and more complete description of this 
operation we respectfully refer the reader to the standard works 
on diseases of women. 

Recto- Vesical Fistula. — When due to malignant disease, 
local operations will be of little benefit and inguinal colotomy 
should be performed at once. The relief afforded will be 
marked and the patient will be made comfortable as long as he 
may live. On the other hand, when the communication be- 
tween the bowel and the bladder has been caused by an injury 
or an abscess, a local operation will often prove a success. In 
case the patient refuses to have the knife used, the application 
of caustics to the opening, or, better still, the actual cautery 
will sometimes induce healing. Mr. Edwards, of London, 
reports two cases cured in this way. 

Becto- Urethral Fistula should be treated by cauterization, 
actual or medicinal, or the edges of the fistulous opening 
should be pared off and sutured together. The judgment of 
the operator must be used in the treatment of this variety, for 
the operation suitable to one might not do for another. Strict- 
ure is the most potent cause of this form of fistula, and must 
be relieved first, else any operative procedure for the cure of the 
fistula will prove a failure. 

Before referring to the after-treatment we desire to review 
briefly some of the more salient features connected with the 
operations for the cure of fistula : — 

1. Always operate under rigid aseptic conditions. 

2. Be certain that all sinuses and diverticula have been 
divided. 



92 DISEASES OF THE RECTUM AND ANUS. 

3. See that the director is not forced out of the main tract 
into the neighboring tissues. 

4. Divide the sphincter at a right angle and not obliquely. 

5. Ligature or twist all spurting vessels. 

6. Guard against injuring the peritoneum when the sinus 
is high up. 

7. Guard against cutting the vagina, prostate, or urethra 
when the sinus is in the anterior wall of the rectum. 

8. Do not operate on patients suffering from acute phthisis 
or Bright's disease. 

9. Give patients the benefit of the sun as much as possible. 

10. Do not pack the dressings tightly after the first twenty- 
four hours, but lay the gauze loosely in the bottom of the tract. 

11. Warn your patient of the possibility of incontinence's 
following the operation. 

12. Be guarded in your prognosis. 

After- Treatment. — The after-treatment of fistula is of almost 
as much importance as the operation itself; for, undoubtedly, 
many of the failures following operations for fistula have been 
due to inattention in taking care of the wound while granulating 
or to meddling with it too much. Our plan is to pack the 
sinus firmly with gauze immediately after all bleeding has been 
arrested. This dressing is then left in situ for twenty-four hours, 
by the end of which time the dressing has become hard and dry, 
necessitating a change. The gauze can be removed slowly and 
with little pain if a stream of bichloride solution is allowed to 
play upon it. The wound is then thoroughly cleansed with 
peroxide of hydrogen, carbolic acid, or boiled filtered water, 
after which fresh gauze is laid loosely in the bottom of the sinus 
to insure its healing from the bottom. We have time and again 
seen healthy granulations arrested by too frequent dressings and 
where the dressings were packed too firmly in the sinus. The 
wound should never be probed unless there is positive evidence 
that pus is forming in the deeper tissues. When this occurs 
there will be a sudden rise in the temperature and an increase 



RECTAL AXD ANAL FISTULAS. 93 

of pain. As a rule, it will not be necessary to tie the bowels 
with opium, as many surgeons do. when the patient has been 
properly prepared for the operation. The diet afterward is 
light and should be confined to fluid and semi-solid foods, Or- 
dinarily the bowels will not move of their own accord before the 
third or fourth day. and sometimes not for a week. When they 
do not move on the fourth or fifth day a dose of castor-oil. -alts. 
or a Seidlitz powder is prescribed, to be followed by an injection 
of warm water to soften the movement. Any one of the reputable 
mineral waters known to have a cathartic action may be pre- 
scribed with satisfaction. After each action the parts should be 
cleaned and fresh dressings applied. The food must be limited 
to strong soups, soft-boiled eggs, and actual beef-juice, until the 
fistula is healed sufficiently to permit the passage of full-sized 
motions without harm's being done. The pain, after these 
operations, is usually very slight, except at the time when the 
dressing is made. In case the pain is sufficient to keep the pa- 
tient awake, one-fourth grain of morphine hypodermatically is 
prescribed at bed- time. It produces the desired effect and 
seldom has to be repeated after the first night. For the first 
few days all patients are required to rest quietly in bed. after 
which time they are allowed to lie on a lounge in the sunshine, 
but must not walk about until the sinus has almost entirely 
healed, for too much exercise tends to arrest granulation. The 
most important thing in the after-treatment is to see that the 
sinus heals from the bottom. In many cases there will be a 
tendency for the skin to bridge over near the anus, leaving a 
channel below. This must be broken up with a probe. It is 
well. also, to look out for burrowing sinuses. They will be in- 
dicated by a rise of temperature, increased pain, and a more 
abundant discharge than would be expected from the original 
granulating sinuses. When such sinuses are found they must be 
laid open at once and treated like the original one. When gran- 
ulations are sluggish or arrested, simple irrigation will not be 
sufficient, and some stimulant must be applied. There are many 



94 DISEASES OF THE RECTUM AND ANUS. 

good ones, such as balsam of Peru, nitrate of silver ten grains 
to one ounce, carbolic acid, zinc, calomel, carbolized oil, and the 
stearate of zinc with iodoform, etc. We prefer lotions and 
powders to ointments, because they do not soil the linen and do 
quite as well. 

PROGNOSIS. 

Patients almost constantly inquire how long the operation 
will confine them to the bed. This question cannot be answered 
with any degree of certainty until after the operation, for a 
fistula that at first appears to be a simple one may prove to be 
complex, having many sinuses leading off in different directions 
from it. Operations for fistula seldom terminate fatally unless 
the cutting has been very extensive. The time required for 
patients to get well depends on the vitality of the patients and 
the magnitude of the operation. An ordinary case will get 
well in two weeks ; in others, when the sinuses are long and 
deep, it will take from four to six weeks and even longer. 

ILLUSTRATIVE CASES. 

Case TIL — Horseshoe Fistula. 

Mr. L., referred to me by Dr. Ketchersid, of Hope, Kansas, aged 38 
years, farmer, came under m} r care suffering from a fistula. He attributed 
its origin to an injury received from a fall upon the frozen ground that 
gave rise to an abscess, which pained him a great deal for several days. 
He applied poultices ; the fistula pointed and was lanced on the eighth 
day and the pus evacuated. The incision made was too small and, in 
spite of fresh poultices, it closed again. The pain and throbbing 
returned for a few days, when it burst and a large quantity of pus 
escaped. This tiling occurred a number of times; every time the open- 
ing closed a new abscess formed and new openings would appear on the 
buttocks above and in front of the anus in the perineum. During this 
time his suffering had been very great, notwithstanding the fact that he 
had used many medicines, lotions, and ointments. One gentleman pro- 
posed an operation, but this he refused, because he did not want to be 
confined to bed. At length his suffering became so great that he con- 
cluded to submit himself to proper treatment. When I first saw him 
his general health was good and ho complained of nothing except the 



RECTAL AND ANAL FISTULAS. 



95 



pain and itching caused by the discharge, which kept the parts about the 
anus irritated. The skin immediately surrounding the openings was of a 
dull, purplish-red color, and the indurated, fistulous sinus could be easily 
traced along the subcutaneous tissues with the linger; live well-marked 
openings were located (see Fig. 41), — two in the perineum, two on the 
left buttock and one on the right buttock; one of the perineal openings 
was just below the scrotal attachment near the centre, the other was one 
inch (2,54 centimetres) below and a little to the left of the upper one. On 
the left buttock one of the openings was one and a half inches (3.76 




Fig. 41.— Horseshoe Fistula with Multiple Openings. 



centimetres) from and a little above the anus, while the other was below 
and about one inch (2.54 centimetres) from the anus. The opening (see 
Fig. 41) on the right buttock was situated far out on the buttock, about 
five inches (12.7 centimetres) from the anus. On examination I found 
that the perineal openings communicated with each other and with the 
openings upon the left buttock, but none communicated with the rectum ; 
and, further, that the one on the right side did, for I could pass a probe 
through the outer opening and it entered the rectum at least two inches 
(5 centimetres) above the anus. Digital examination revealed the 
presence of a firm fibrous or cartilaginous band about an inch (2.54 



96 



DISEASES OF THE RECTUM AND ANUS. 



centimetres) thick, extending across the rectum nearly two inches (5 
centimetres) above the anus. The patient was ordered to take a bath, 
two teaspoonfuls of licorice-powder to be taken at once, and an injection 
to be given on the following day, one hour previous to the time set for 
the operation. The parts having been previously shaved and the patient 
thoroughly anesthetized, a groove director was passed from one perineal 
opening to the other and all intervening tissues were divided. Then the 
sinus extending thence to the upper opening on the left buttock was 
divided, after which the director was easily made to pass into and 




Fig. 42 —Lines of Incisions showing how the External Sinuses were Made to Com- 
municate with Eacl) Other and with the Rectum and the Sphincters Severed but 
Once, and then at a Right Angle. 



through the lower opening on the same side, which was treated in a 
similar manner. A careful search was made to see if there were any com- 
munication with the bowel, but none could be located, and I directed my 
attention to the opening on the right buttock. It was found that an 
ordinary groove director was far too short to reach from the external 
opening into the bowel, and a long and very strong steel director was 
selected and passed into the external and through the internal opening 
within the bowel, where it could be felt with the index finger of the left 
hand introduced for that purpose. It was found that the tissues to be 
divided were so firm and thick that the internal end of the director could 



RECTAL AND ANAL FISTULAS. 97 

not be brought outside the anus as in ordinary cases. A strong and sharp- 
pointed bistoury was then passed along the director until it could be felt 
in the bowel, when it was pressed into a piece of pine-stick to prevent 
doing an}- damage. The knife and stick were then drawn out at the 
same time, dividing all tissues between them. (See Fig. 42.) A short 
sinus running at right angles to the main one was found and divided. 
Thus all the sinuses were made to communicate with each other. 

When all the sinuses had been divided, they were curetted and 
Salmon's back-cut made along the back of each one. After this they 
were irrigated with a solution of bichloride and tightly packed with 
iodoform gauze and cotton, and the patient ordered to bed with instruc- 
tions to have an hypodermatic of one-fourth grain of morphine, in case 
he suffered much pain the first night. The dressings were not changed 
until the second day, when they were replaced. The only difference in 
the dressing was that the gauze was placed loosely in the bottom of the 
sinus, for there was no fear of hemorrhage after the first twent3'-four 
hours. The dressings were changed every other day for three weeks, at 
the end of which time all the sinuses were completely healed, and the 
patient returned to his home happy. I received a letter some months 
later saying that he was entirely well. 

Case YIII. — Blind Internal Fistula. 
A lady was sent to me from Kansas to be treated for some rectal 
trouble with the following symptoms : She said she had been constipated 
for several years ; did not have more than two actions a week ; and then 
strong purgatives were used. She was very nervous, and suffered almost 
constant pain in the rectum, which was very much worse during and 
after defecation. The pains were sometimes reflected up the back and 
down the limbs. There was no bleeding at any time, and very little dis- 
charge ; once or twice there had been a small amount of pus on the 
feces. On examination the rectum and anus seemed perfectly healthy, 
except that the sphincter was tightly contracted and very much thick- 
ened. I came to the conclusion that her trouble was due largely to con- 
stipation, the result of the feces becoming impacted and pressing upon 
the nerves, causing a reflex spasm of the sphincter muscle that was 
largely responsible for the pain. Divulsion was decided upon and done 
thoroughly ; a large-sized Pratt speculum was introduced and a careful 
examination made, which revealed the presence of a small, inflamed area 
about one inch (2.54 centimetres) above the anus. In the centre was a 
little pocket formed Ivy the transverse folds of the mucous membrane. 
A small probe was selected and pressed first on one place and then 
on another until an opening was found. The probe passed beneath the 



98 DISEASES OF THE RECTUM AND ANUS. 

membrane and downward toward the surface until its point could be 
felt about one inch backward and a little to the left of the anus. The 
author's angular groove director was then made to take the place of the 
probe and was pressed against the skin. An incision was made over the 
point, and it was forced through the skin and all the tissues thereon 
divided. The wound was treated as after an ordinary operation for 
complete fistula, and the patient was perfectly well at the end of three 
weeks. I report this case simply because it shows just how easily we 
may be mistaken in our diagnosis unless we use extraordinary care in 
making an examination, even when chloroform is used for that purpose. 



CHAPTER XI. 

THE RELATION OF PULMONARY TUBERCULOSIS 
TO FISTULA. 

This subject is one of much importance and is deserving 
of special and separate consideration, for any surgeon who 
operates frequently for fistula in ano will notice the frequency 
of phthisis as a complication. Then the questions arise: Ought 
we to operate on such cases'? If we operate on some of them, 
what signs or symptoms must be our guide in selecting cases 
that are likely to improve after the operation ! These questions 
are difficult ones to answer, for it is not easy to draw the line 
between those that are and those that are not fit subjects for 
operation ; yet by making a special study of each case it can be 
done, as we will attempt to show farther on in this chapter. 
There has been much difference of opinion as to the relative 
frequency of one of these diseases to the other. Probably from 
4 to 6 per cent, of all phthisical patients have fistula, while a 
much larger percentage of those afflicted with fistula have 
phthisis, — namely, from 12 to 15 per cent. It has been our lot 
to meet a large number of cases of fistula complicated with 
phthisis daring the last few years, and we do not hesitate to say 
that they have worried us not a little. In tubercular ulceration 
we have two varieties, — one where the little tubercles can be 
located in the rectum about the ulcerated spots, while the other 
variety consists of a simple ulceration, in a debilitated patient 
afflicted with tuberculosis of the lungs. So we meet with two 
kinds of tubercular fistula, — one as a result of 'localized tubercular 
ulceration with or without any lung complication ; the other, a 
fistula in persons who have lung trouble due to the absorption 
of fat about the ischia, general debility, and abscess. In the 
feces of the first variety can be found the tubercle bacilli of 
Koch, while in the second variety they cannot be found unless 

(99) 



101) DISEASES OF THE RECTUM AND ANUS. 

sputum containing them has been swallowed and gastric digestion 
has been impaired to such an extent as not to destroy them or 
their spores. 

Symptoms. — The patient's general appearance, the symp- 
toms and local changes of one afflicted with a tubercular fistula 
are so distinctly different from the ordinary fistula that a sur- 
geon who has seen one case will have no difficulty in diagnosti- 
cating another. A person thus afflicted will be run down in 
general health and have a sallow complexion. Many of them 
are annoyed by a cough. The anus will be found patulous and 
surrounded and almost hidden by an abundance of long, silky 
hairs ; the ischio-rectal fossae are apparently drawn in, owing to 
the absorption of fat ; the external opening of the fistula is large 
and irregular in shape, and the skin surrounding it is of a bluish 
tint, and the edges droop down into the opening. On passing 
the finger or probe into this opening it can be made to sweep 
around in almost any direction for an inch or so beneath the 
undermined skin. At the same time it will be observed that 
the fistula has not burrowed deeply. On passing the finger 
into the bow 7 el the internal opening will be located, usually 
within an inch of the anus, and it, like the external, is large 
and the edges irregular. These patients have little pain except 
from excoriations. Not infrequently the destructive process has 
been so extensive that the finger can be pressed through the 
external opening and into the bowel with ease. The discharge 
is usually abundant, thin, and watery. What a contrast to the 
ordinary fistula with its small openings, tight sphincter, rounded 
buttocks, increased pain, etc. ! 

Treatment. — Having mentioned some of the most impor- 
tant diagnostic features, we will proceed to the treatment, which 
in a large measure should be operative. Now and then, how- 
ever, we find a case that we can at least make comfortable or 
even effect a cure by less radical treatment. Now to the 
important questions put in the beginning of this chapter: 
" Ought we to operate? If so, on what class of cases'? " 



RELATION OF PULMONARY TUBERCULOSIS TO FISTULA. 101 

These questions have been studied and discussed as fre- 
quently as almost any other subject connected with rectal 
surgery, and yet no definite conclusions have been reached. 
Some high in authority believe that we should not operate on 
this variety of fistula under any consideration ; others equally 
high claim that we should. Recent writers on this subject, 
however, especially those who are doing a large amount of 
rectal surgery, look more favorably on operative procedure than 
did the earlier writers. The reasons given for non-operative 
interference have been vague in many respects. Some say not 
to operate, for the wound will not heal ; others, that if we operate, 
the lung trouble, when present, will be aggravated and the 
patient will die ; and, in cases where no lung trouble has de- 
veloped, if the sinus is healed there will be no outlet for the 
discharge, and, in consequence, a lung trouble will be produced. 
There is some excuse for the first assertion, for it cannot be 
denied that occasionally a tubercular fistula refuses to heal, and, 
further, that they all heal much more slowly — due to the cough 
and low vitality — than an ordinary fistula. At the same time 
we have witnessed many favorable results in our own practice 
as a result of operative procedure. The other reason for not 
operating — namely, that the lung complication will be increased 
as a. result of the arrest of an unhealthy discharge — has no 
foundation. The quicker such reasoning is done away with, the 
better it will be for these sufferers. We know that there is no 
intimate anatomical relationship between the lungs and the anus 
or the tissues immediately surrounding it, and just why the 
arresting of a destructive process in the one should affect the 
other is not sufficiently apparent of itself to condemn opera- 
tive procedure. 

We are justified, then, in operating on all those patients 
suffering from a tubercular fish da in its strictest sense, and also 
those who have a simple fistula with lung complications, pro- 
vided the patient's general condition will permit it. It is the 
condition of the patient at the time we are consulted that should 



102 DISEASES OF THE RECTUM AND ANUS. 

decide this question, and not the fact that the patient may have 
a localized tuberculosis, either in the anal region, lungs, or 
both. We desire very much to emphasize this fact, for we 
have seen many patients who suffered for years and would not 
submit to an operation because they had been told by some one 
that, because they had a predisposition to phthisis, if the fistula 
were healed they would die of lung- trouble. It is not an easy 
matter to lay down a given rule to go by in the selection of 
cases whose condition would be improved after an operation. 
It is safe to say, however, that we certainly should not operate 
on patients we know to have acute phthisis, — that is, where 
the lung trouble is of recent date and is progressing rapidly. 
When the patient is emaciated, has shortness of breath, night- 
sweats, almost constant coughing, etc., he will in all probability 
die in a few weeks of the lung trouble. An operation would 
only cause him more suffering and the sinus would not heal, 
owing to the constant and rapid lowering of vitality. In such 
a case all we can do is to use cleanliness, soothing lotions, and 
ointments to make him comfortable while he does live. To 
clean and stimulate the wound any of the ordinary antiseptic 
solutions — such as Condy's fluid, carbolic acid, and bichloride — 
will do as well as any after the sinus has been syringed out with 
the peroxide of hydrogen. In addition, codliver-oil, creasote, 
and tonics should be prescribed to build up the system in general. 
In spite of anything that can be done, many of these patients 
will not improve in the slightest, but will rapidly decline until 
death claims them. On the other hand, we are justified in 
operating on all cases that have phthisis where the destructive 
process is sloir and where the fistula is causing some pain, 
lowering vitality, and causing much mental worry as a result of 
the constant and profuse discharge. It cannot be denied that 
many who have had fistula, and tuberculosis of the lungs have 
recovered. Knowing this to be a fact, and that the discharge 
from a fistulous tract is very exhausting to both mind and body, 
we should operate and endeavor to stop this great drain upon 



RELATION OF PULMONARY TUBERCULOSIS TO FISTULA. 103 

the system and thereby immediately help the lung trouble. It 
is much easier for nature, assisted by us, to take care of one 
destructive process than two, as was the case previous to the 
operation. When it has been decided that the case under ad- 
visement is one suited for an operation, there are many pre- 
cautions to be taken before and after the operation. In the 
first place the patient's general health should be improved as 
far as possible by tonics and nourishing diet, such as milk in 
large quantities, eggs, pure beef-juice, rich soups, etc. Xot 
infrequently a little trip to the sea-side Avill prove beneficial, 
both from the sea-breeze and the change of scenery. The 
bowels should be moved, the rectum washed out, and the patient 
is ready for the operation. 

As regards the anesthetic to be used, chloroform should 
always be selected when lung trouble is present, unless there be 
some marked contra-indication, for ether has a tendency to 
irritate the air-passages and cause an increased secretion of 
mucus in the same. From personal experience we have been 
led to believe that many of the deaths following operations 
on this class of fistula have resulted from inflammation of the 
lungs induced by the administration of ether, and not as a result 
of the cutting or closure of the fistulous sinuses. Chloroform 
rarely ever causes any irritation of the air-passages. The oper- 
ation differs slightly from that for ordinary fistula in that it 
should be performed quickly and in such a way as to have 
little bleeding, as the amount of blood lost to these patients is 
of vast importance. Caution should be used not to incise the 
sphincters too freely, especially the internal sphincter, owing to 
low vitality. When they are cut once, incontinence may 
follow ; and if they are cut two or more times, incontinence will 
certainly follow. After the sinus has been laid open it should 
be curetted and the skin alone: its edo-es trimmed. The wound 
should be packed and the patient immediately placed in a warm 
bed and surrounded with hot bottles and given stimulants if 
there is any tendency to shock. 



104 DISEASES OF THE RECTUM AND ANUS. 

After- Treat nun t. — The patient should not be allowed to 
stay in bed after the third day, but must be made to get up and 
lie on a lounge, near a window, where he may have the full 
benefit of the sun. Just as soon as the weather and his con- 
dition will permit, he should be required to spend most of his 
time out in the fresh air sitting about. Unless his hygienic 
surroundings are looked after, the operation is likely to prove 
a failure. The wound requires the same kind of treatment as 
that of an ordinary fistula. All tonics and nourishments that 
proved beneficial in building the patient up previous to the 
operation should be continued afterward until he is in a fair 
way to recover. There is one more point connected with the 
after-treatment that we desire to mention before closing this 
chapter, — namely, that it is not well to have the bowels move 
oftener than every third or fourth day, for the frequent use of 
purgatives may be the means of starting a diarrhea that will be 
difficult to arrest, which exhausts the patient very quickly and 
delays healing from the irritating discharges passing over the 
wound. 

ILLUSTRATIVE CASES. 

Case IX. — Tubercular Fistula. 

Mr. P. was referred to me by Dr. Chassagne, of Kansas City, who 
had been treating him for phthisis. Two months prior to the time he 
eame to me a large abscess formed on the right buttock, burst, and a 
fistula was formed from which large quantities of a thin-looking pus was 
discharged. lie suffered much pain, was weak and almost exhausted. 
He had the ordinary symptoms of phthisis, — hemorrhages, cough, and 
night-sweats. On examination the upper portions of both lungs were 
found to be involved. An operation was decided upon and I determined 
to try the elastic ligature, as used hy Mr. Allingham, so that there would 
be no blood lost and he would not be confined to his bed. Both the 
external and internal openings bcing'large, a probe, threaded and stitched 
to the rubber ligature, was easily passed through the external opening 
into the rectum and brought out at the anus, thus including all the 
tissues to be divided. The ligature was then made taut and the ends 
were passed through a piece of lead with an opening in the centre. By 
the aid of strong forceps the lead was pressed together and the ligature 



RELATION OF PULMONARY TUBERCULOSIS TO FISTULA. 105 

made secure. The whole procedure did not take more than five minutes 
and caused very little pain. Tonics and nutritious food were ordered 
and he was told to spend all his time in the fresh air when the weather 
would permit. In two weeks the ligature cut its way out and left a 
healthy, granulating siuus, which was dressed as after the ordinary oper- 
ation for fistula. In two months from the time he came to me for treat- 
ment the fistula was well and he had improved very much in general 
health. 

Case X. — Tubercular Fistula. 

Mr. J. C, aged 27, referred to me from the country, was suffering 
from chronic phthisis and from a fistula in ano. the latter annexing him 
very much. The discharge was very profuse and kept the surrounding 
parts irritated all the time. On examination it was found to be com- 
plete ; the external opening was large and to the left, and one inch (2.54 
centimetres) below the anus; the opening in the bowel was between the 
external and internal sphincter muscles. The patient was emaciated, 
coughed considerably, and now and then had night-sweats. He had 
been suffering from lung trouble for one year, but there was no evidence 
that he would die from the lung complication for a long time ; conse- 
quently, I decided on the ordinary operation for complete fistula. The 
sinus was divided, curetted, and all of the undermined skin trimmed off 
with scissors. The usual dressings were then applied and the patient 
put to bed and surrounded b}- hot bottles. There was very little shock, 
and on the following morning the patient expressed himself as feeling- 
better than he had for weeks. From this time on there was no increase 
in the lung trouble. He was requested to lie on a lounge in the sunshine 
dail} T after the dressings had been changed until the end of ten days ; 
after which time he was allowed to spend most of his time in the park. 
Tonics and creasote were given, and at the end of six weeks the sinus 
had completely healed. I advised him to go to El Paso, Texas, for a 
few months, which he did. At the end of a 3 T ear he returned home much 
improved in general health and informed me that the fistula was entirely 
well. 



CHAPTER XII. 

INCONTINENCE OF FECES. 

It is difficult to conceive of any more serious accident that 
could follow any operation about the rectum than incontinence; 
for what could be more deplorable, cause more annoyance or 
mental worry than to lose all control ol the bowel? Inconti- 
nence may be caused by either permanent or temporary paral- 
ysis. The latter condition is sometimes brought about as a result 
of some local irritation within the rectum, that excites and keeps 
up a constant spasmodic contraction and relaxation of the 
sphincter until it becomes tired out and remains passive. In- 
continence may be caused by ulceration, benign or malignant, 
where one or both sphincters have been destroyed. Again, it 
may be the result of any operation about the anus where it is 
necessary to divide the sphincter muscles one or more times. In 
all operations for complete fistula this is necessary ; hence, in- 
continence will follow operations for fistula in ano more fre- 
quently than for any other disease. After operations for fistula, 
patients are frequently unnecessarily alarmed because of their 
inability to retain wind and liquid feces. This lack of sphinc- 
teric power may last for several weeks, until the sinus has 
entirely healed and the cut muscles are reunited. It is well 
to inform patients about to be operated on that they will prob- 
ably not have perfect control of the bowel for a few weeks, and 
that now and then permanent incontinence follows the operation, 
but that all who hope to get well must take this risk. Per- 
manent incontinence occurs more frequently in women than 
in men, and is almost certain to follow an operation where the 
sphincter has been severed at its junction with the sphincter 
vaginae, for it then has no fixed point above; consequently, it 
will be unable to contract sufficiently to completely close the 
anus, and the feces, when fluid, will constantlv leak out at that 
(1<>6) 



INCONTINENCE OF FECES. 107 

point. It is more apt to follow operations where the incisions 
have been carried high up the bowel, above the internal sphincter, 
than where they do not go higher than one inch above the anus. 
It is also more apt to follow where the muscles have been 
divided obliquely than at right angles, and where the muscles 
have been cut two or more times. Sometimes the muscles may 
ue severed several times and incontinence will not follow; on 
the other hand, it has been known to follow an operation where 
the external sphincter alone had been cut. Why incontinence 
follows a comparatively trivial operation in one case, while in 




Fig. 43.— Appearance of the Anus where the Sphincter was Cut in Three Places 
in a Girl who Recovered Perfect Control of the Bowel in Six Weeks. 

another much more cutting is done (see Fig. 43), yet the patient 
will have perfect control of the bowel, has been the subject of 
much study. Explanations have been brought forward by 
prominent surgeons. Kelsey thinks the explanation lies in 
the fact of vicious cicatrization, by which the ends of divided 
muscles are not brought into accurate apposition. If this is 
true, it explains why a single cut may cause incontinence; the 
ends of the muscle being separated by a cicatrix for a variable 
distance, the muscle has no fixed point of support and loses its 
power. In another case it may have been divided in several 
places and afterward have healed in such a way as to leave the 



108 DISEASES OF THE RECTUM AND ANUS. 

segments of muscle united as one undivided circle, without being 
followed by incontinence. Another thinks the incontinence is 
the direct result of dividing the nerves supplying the muscle. 
It is not of so much interest to us to know how or why incon- 
tinence occurs as to be able to correct it. There is no other 
operation in rectal surgery that will prove more gratifying to 
both patient and surgeon than that for incontinence when suc- 
cessfully performed. A patient, once relieved of this deplorable 
condition, never ceases lauding the one who did it. 

Treatment. 

Incontinence may be cured in two ways, — first, by cauter- 
ization ; second, by plastic operations similar to those for re- 
pairing a lacerated perineum in women. It is always essential 
to tell the patient that you may not be able to cure him by the 
first operation ; but it may require two or more, and take sev- 
eral weeks or even months to bring about the desired results. 
If the patient will only put himself in our hands until we are 
ready to discharge him, we can promise material help, if not 
an entire cure. 

Cauterization. — Cauterization for the cure of incontinence 
comes highly recommended from all writers on the subject. We 
have always found the Paquelin cautery to be all that could be 
desired. The extent to which it should be applied is dependent 
upon the nature of the incontinence — that is, whether it is partial 
or complete — and on the condition of the anus. After removing 
any piles, tabs of skin, etc., that might be present, the cautery- 
point at the dull-red heat should be applied to both external 
and internal sphincter muscles in four or five places (see case) 
at an equal distance apart. We have been in the habit of 
pressing the cautery almost through the entire depth of muscles 
to insure decided contraction. Then it is pressed deeply into 
the tissues at the junction of the skin and mucous membrane in 
three or four places ; this insures a marked contraction at the 
anus. If after the first application sufficient contraction does not 



INCONTINENCE OF FECES. 109 

follow, cauterization should be repeated. The operations should 
be at least two months apart, for sometimes the contraction takes 
place slowly. It is surprising how much contraction will follow 
a comparatively slight cauterization, and the relief thus afforded 
is very great. 

Plastic Operation. — The simplest manner of operating is 
to cut the muscle at a right angle at its weakest point ; the ends 
of the muscle on either side of the incision are then seized, fresh- 
ened, and brought into accurate apposition by silk-worm or cat- 
gut sutures, and dressed with antiseptic dressing. If the oper- 
ation prove a success, they will unite by first intention in a few 
days. In fact, the anus can be made just as small as the oper- 
ator desires by additional sutures. In all cases where the ends 
of the muscle can be united, the results will be good. In simple 
cases the plastic operation is preferable, because it effects a cure 
in a few days, and there will not be any abnormal contraction. 
In severe cases where scar-tissue is abundant and the anus 
is wide open all the time, the cautery applied as previously 
described gives the best results; for when such a condition exists 
one could scarcely expect to get union by first intention, o wing- 
to tension on the sutures and impaired circulation in and about 
the scar-tissue. In cases of incontinence due to malignant dis- 
ease, ulceration, and paralysis, the indications for treatment are 
the same as if it had occurred after simple operation. In ad- 
dition to the surgical treatment, constitutional remedies must be 
prescribed for those who are anemic and debilitated. 

ILLUSTRATIVE CASE. 

Case XI. — Incontinence due to Rupture of Sphincter Muscle. 

A few months past Mrs. B. was referred to ine to be treated for 
total incontinence, and she gave the following history: She was 30 years 
old, and had never been sick a day in her life until two years ago. Then 
she had a pain in the region of the tubes and ovaries. She consulted a 
prominent phj^sician of our city, who removed the offending organs. 
After she had recovered from the immediate effects of the operation, he 
informed her that she had piles — which was news to her — and that she 



110 DISEASES OF THE RECTUM AND ANUS. 

must have the rectum stretched. Believing this essential, she consented, 
and was again anesthetized and the operation performed. In due time 
the abdominal wound healed and she was discharged. She returned to 
her home to assume her household duties. During this time she had no 
control of the bowels, and the feces passed out as quickly as they entered 
the rectum, which was very annoying and necessitated the wearing of 
a napkin constantly. The surgeon was consulted, and he replied that 
the muscle would regain its power in a few weeks ; but it did not, and, as 
the weeks and months rolled by and no improvement was noticeable, she 
insisted on something's being done. He at last endeavored to repair the 
injury by a plastic operation similar to that used for the repair of the 
perineum. It was a failure, as were the two subsequent ones performed 
several months apart. At this time the patient decided to try some one 
else, and was referred to me. Examination revealed the presence of many 
scars in the anal region and complete loss of sphincteric power. I told 
her of the state of affairs, and said I believed that she could be benefited 
very much and possibly cured, as far as the leakage was concerned, if she 
would place herself absolutely in my hands until she was discharged. 
She readily consented, for life was simply unbearable in her then con- 
dition. Two days later I operated at All-Saints Hospital, before the 
members of the post-graduate class, after the following manner: She was 
placed in the lithotomy position with the limbs well flexed upon the ab- 
domen. A large bivalve speculum was introduced and the rectum irri- 
gated, after which it was wiped perfectly dry. With the Paquelin cautery- 
point I made a number of deep linear burns into the rectal wall, about 
three quarters of an inch (1.8 centimetres) apart, beginning at the upper 
margin of the internal sphincter muscle and terminating in the skin just 
without the external sphincter. Strips of iodoform gauze were smeared 
over with vaselin and placed in the rectum to keep the walls apart. 
Three days afterward the gauze was removed, the rectum irrigated, and 
fresh gauze replaced. The rectum was dressed in the same way for three 
weeks, when she was discharged from the hospital able to retain solid 
feces. I informed her that the contraction would be more in several 
weeks, but that it was possible that another operation might be required, 
and for her to come to the ofliee from time to time. Last month I saw 
her. nine months from the time she left the hospital, and she could retain 
liquids and solids without any difficulty, and was very grateful for the 
services rendered her. I have reported this case at length, because it 
shows how easily incontinence may be produced, and to point out the 
most satisfactory way of relieving it. 



CHAPTER XIII. 

FISSURE AND PAINFUL ULCER. 

That fissure of the anus is a very common affliction none 
can deny, for we are all familiar with a large number of people 
who suffer from it. We all know how common constipation is, 
and it has been observed that constipation is the most potent 
cause of fissure. In fact a very large percentage, if not all, who 
suffer from constipation have had or will have a fissure at some 
period of their existence. It is necessary to impress this fact 
so that the attention of both the physicians and the laity may 
be drawn to this subject, that they may be on the lookout for 
this common evil and at once recognize it. It is a condition 
that can be easily and speedily corrected. Fissure has been 
written and talked about since the time of the ancients to the 
present day, sometimes under one name, sometimes under 
another, but it did not receive that special consideration it so 
much deserved until about sixty years ago, when M. Boyer 
gave it his special attention, he having had a large experience 
in the treatment of this disease in its various forms. He would 
lead us to believe that all cases of fissure are accompanied by a 
painful anal spasm of the sphincter ani muscle, and that this 
painful contraction in reality constitutes the disease, whether 
attended by a rent in the mucous membrane or not, and that 
the disease is not in the mucous membrane itself, but that it is 
in the sphincter muscle alone. Bodenhamer, in his most excel- 
lent and exhaustive work on "Anal Fissure," says that the 
ancients, when speaking of fissure, did not mention anal spasm, 
and, further, that while M. Boyer's friends claim for him the 
distinction of being the first to point out that anal spasm always 
accompanied anal fissure, they are mistaken. Nearly three 
hundred years previous to his time the celebrated French sur- 
geon, Ambrose Pare, in describing fissure, said it was attended 

cm) 



112 DISEASES OF THE RECTUM AND ANUS. 

by great contraction and narrowing of the anus. Great credit, 
however, is due M. Boyer, for he did all he could to show the 
importance and frequency of this disease. We cannot concur 
in his belief that the disease is in the muscle primarily, and not 
in the mucous membrane. He admits that the membrane may 
or may not be diseased. It is our opinion that the spasmodic 
contraction of the sphincter ani is a secondary matter, due to 
an irritation arising from a localized diseased condition of the 
mucous membrane near the anal margin. That there is more 
or less spasmodic contraction of the sphincter ani accompany- 
ing every case of fissure of long standing cannot be disputed, 
and, further, that there may be a spasmodic contraction of the 
sphincter without a rent in the mucous membrane is equally 
true, due to some other pathological conditions of the rectum 
and anus, or from reflex action as a result of an irritation set up 
by some neighboring organ. Therefore, we are not justified in 
saying we have a fissure in ano simply because there might be 
a spasmodic contraction of the sphincter muscles, as M. Boyer 
teaches. 

There are other authors who, like M. Boyer, believe that 
spasmodic contraction of the sphincter ani is an idiopathic 
disease of itself, not dependent upon any rent or erosion that 
might or might not be present, and constitutes the condition de- 
scribed an fissure in ano. Others equally high in authority take 
an opposite view. They believe that the spasmodic contraction 
of the sphincter is not the prime factor, but a secondary one in 
the disease, and that the contraction is directly due to an irrita- 
tion caused by some rent or irritation at the margin of the anus 
or lower portion of the rectum. The former claim that the rent 
is present by accident or is produced by the spasmodic contrac- 
tion ; while the latter, as previously stated, think the contraction 
is secondary to the rent. We are inclined to believe that the 
latter gentlemen are right, for in a large number of cases that 
we have treated we have frequently seen a rent in the bowel 
when there was no sphincteric contraction. Later on, however, 



FISSURE AND PAINFUL ULCER. 113 

the rent or fissure would become irritated from some one of a 
number of causes, and contraction of the muscle would then 
follow, and, as a rule, would continue until the fissure was 
cured. Whenever this spasmodic contraction commences, the 
irritation of the fissure is increased and the'painbecomes almost 
unbearable. Knowing this, we might very well divide tins dis- 
ease into two stages, — first and second. The first stage com- 
mences at the time the rent in the mucous membrane is made 
and continues until the fissure becomes irritated and induces 
muscular spasmodic contraction, which marks the beginning 
of the second stage and is also the pathognomonic sign of an* 
irritable fissure. In the first stage there will be a slight itching, 
but very little pain ; while in the second stage the pain is very 
greatly increased. 

It will be observed that this chapter is headed " Fissure 
and Painful Ulcer." We have chosen this heading because 
we believe that the term fissure by itself would not give 
a correct idea of certain conditions described in this chapter 
which have been heretofore denominated fissures. A simple 
fissure, cleft, rent, or crack, whichever you choose to call it, may 
from certain causes become enlarged and circular or oblong in 
shape with roughened edges, losing all its former characteristics 
except, perhaps, its irritability ; then, according to our concep- 
tion, it is no longer a simple fissure, but simply an irritable ulcer. 
An ulcer may start as such from the beginning, never at any 
time having the appearance of a fissure. The symptoms of 
these two conditions are the same, the only difference being in 
their shape. In fissure there is simply a narrow, elongated rent 
in the mucous membrane at or near its junction with the skin, 
the edges of which are on a level and in contact with each other 
unless kept apart by a small fecal mass. On the other hand, 
the ulcer will be circular or irregular in shape, with rounded or 
raised edges and of variable size. If there is any difference in 
location, it is that the fissure is found more frequently near the 
anal margin than is the ulcer. The following remarks treat of 



114 DISEASES OF THE RECTUM AND ANUS. 

those two conditions as if they were one, the symptomatology 
and treatment being practically the same. In order to avoid 
confusion we will use the term painful ulcer in speaking of 
them. 

Etiology of Painful Ulcer. 

The causes of painful ulcer of the rectum are many, and 
the most common of these is constipation. By careful observa- 
tion it at once becomes apparent why this is, for we all know 
how delicate the mucous membrane is and how readily it tears; 
how easy it is for a rent to be made in the same, when an action 
has been deferred for some time and the feces have become so 
hardened that great straining is required to expel the fecal 
mass. The rent may be caused by the mucous membrane's 
being scratched by some hard substance in the concreta or from 
the stretching of the same by a large knotty mass while passing 
through the sphincter. Again, constipation may cause an ulcer 
from pressure when the mass has collected in the rectum and 
remained there for any great period. We have observed this 
frequently in cases of impaction. Then, again, may not the 
mucous membrane be irritated from certain irritant substances 
to be found in retained feces'? On the other hand, we may have 
an ulcer caused by diarrheal or dysenteric discharges because 
of their irritating qualities. Ulcers are found more frequently 
in women than in men, probably because more of them suffer 
from constipation. Comparatively few children suffer from this 
complaint unless there has been a narrowing of the anus ; yet 
it has been our privilege to see three cases in children as a 
result of severe straining during an attack of constipation. Dr. 
Daniel Morton believes that fissures are frequently produced in 
children who suffer from constipation. Certain diseased con- 
ditions of the uterus, bladder, or prostate that induce straining, 
and injuries to the rectum by foreign bodies swallowed or intro- 
duced from below, — such as pins and fish-bones, — or the care- 
less introduction of the nozzle of a syringe, may be causes. Any 
morbid growths — such as piles, polypi, malignant disease, etc. — 



FISSURE AND PAINFUL ULCER. 115 

that induce straining or cause an irritating discbarge may be 
put down as causes. Tbe same might be said of any skin or 
venereal disease situated about the lower end of the rectum or 
immediately without the anus, such as eczema and vegetating 
warts. Hypertrophied tags of skin and external piles are fre- 
quent causes. In fact, painful ulcers have been found so fre- 
quently within the folds of an external pile that such a pile has 
been designated a sentinel pile. Surgical operations for the cure 
of hemorrhoids may be the cause of a painful ulcer where the 
wound refuses to heal. There are certain conditions that some- 
times produce a painful ulcer, and, at the same time, may be the 
cause of some other pathological condition about the rectum, 
which necessitates a careful examination in order that the treat- 
ment may be successfully carried out. 

Symptoms. 

A painful ulcer is ordinarily found in those who suffer only 
from it and constipation, brought on by an in-door life and irreg- 
ular habits. This disease, we think, causes more severe pain, 
reflex manifestations, and mental worry than any other disease 
that we are likely to be afflicted with, where the pathological 
condition of the parts afflicted is of such slight moment. We 
have, in a large number of cases, seen stout and apparently 
healthy men entirely incapacitated for their usual duties, as the 
result of a slight rent in the mucous membrane the thickness 
of a pin and not more than half an inch (1.27 centimetres) in 
leno-th. This, of course, is after the ulcer has become irritated 
and spasm of the sphincter inaugurated. The symptoms, how- 
ever, are usually characteristic in spite of the fact that the 
patient insists that he has the piles. 

Pain. — The pain is paroxysmal, is very severe, comes on 
during the act of defecation, and lasts during the same and 
for a variable length of time afterward. In one case it may last 
only a few moments, while in another it will last for half a day 
and exhaust the patient very much ; for this reason persons 



116 DISEASES OF THE RECTUM AND ANUS. 

who are aware that they have this painful condition will post- 
pone going to stool as long as they can ; then, when an action 
Joes take place, it is something fearful on account of the size, 
shape, and compactness of the feces. The pain is described as 
being of a severe, smarting, tearing character, and is often re- 
flected to the coccyx, perineum, pelvis, up the back, or down 
the limbs to the toes. It is not an uncommon thing for a man 
afflicted with painful ulcer to complain of pain in the heel or 
toe during defecation. The after-pain is kept up and made 
more severe by the spasmodic contraction of the sphincter, which 
may last from a moment to many hours. Frequently the patient 
will not suffer between stools, for the pain is rarely constant. 
The pain, while it lasts, is so severe that patients easily fall into 
the habit of taking an hypodermatic injection of morphine or 
some narcotic just previous to going to stool to obviate the 
after-pains, and may become slaves to drugs. For this reason 
the promiscuous administering of drugs for the relief of pain 
cannot be too severely criticized. 

Bleeding from painful ulcers varies very much. Some do 
not bleed at all ; others, very slightly, — that is, on examination, 
the expelled fecal mass will be found to be streaked with blood; 
while still others bleed profusely, even until they faint. The 
bleeding may not last long or it may last many hours. Pa- 
tients have informed me that they have been obliged to go 
about their daily vocation with blood trickling down their legs, 
because they did not have time to wait until it stopped. 

flatulence is a frequent symptom. Bodenhamer says he 
never saw a severe case in which it was not present to a greater 
or less extent, dependent sometimes upon the length of time 
since the bowel was emptied, for it is not an unusual thing for 
the bowels not to move oftener than once a week unless an 
injection or purgatives are prescribed to soften the stool. 

When the ulcer is of long standing and the suffering has 
been severe, patients thus afflicted become very nervous and 
imagine they have a cancer or some other serious disease ; their 



FISSURE AND PAINFUL ULCER. 117 

features are pinched, indicating suffering, and in some cases 
they become physical and mental wrecks. 

Physical Exploration. 

Preparatory to an examination, the bowels should be un- 
loaded by means of a mild purgative, followed by a copious 
injection of warm water and Castile soap. It is optional with 
the surgeon as to the proper position ; either the Sims or the 
lithotomy position is good. Frequently the fissure can be 
located without causing much pain by placing a small piece of 
cotton saturated with a 6-per-cent. solution of cocaine within 
the anus and leaving it there for a few moments. It is always 
desirable to make the examination under the influence of an 
anesthetic, if the patient will consent, for it can and will be 
made more thoroughly than it otherwise would be when the 
patient is squirming around and telling us how badly we are 
hurting him. It enables one to diagnosticate other complications 
that may be the cause of the ulcer situated high up in the rec- 
tum. With a good light and with the nates well separated by 
an assistant, any external abnormality will be readily detected. 
When a fissure is present the sphincter is nearly always mark- 
edly contracted, so much so in some cases that the anus is 
funnel-shaped,— -a condition similar to that described by French 
surgeons as being present in those guilty of sodomy, which is. 
said to be very common and on the increase in their country. 

Sometimes some skin disease that may be the cause will be 
detected. Painful ulcers about the anus are not uncommon in 
young children who have inherited syphilis. We well remember 
seeing at the dispensary three little girls w 7 ho were, respectively, 
2, 5, and 8 years old, born of syphilitic parents, who had these 
ulcers to a distressing degree, as well as other manifestations of 
this loathsome disease. If there is any external pathognomonic 
sign of an ulcer, it is to be found in the little external pile which 
marks its location and not infrequently hides the fissure within 
its folds. We have previously designated this a sentinel pile. 



118 DISEASES OF THE RECTUM AND ANUS. 

Sometimes the ulcer can be easily located, for the lower end 
comes into view at the muco-cutaneous junction. (See plate.) 
At other times the surgeon will have a chance to display all 
his ingenuity ere it is located. When external examination 
fails to reveal its presence, it will be necessary to resort to a 
digital or specular examination. The latter will be preferable, 
in the majority of cases, for it is not an easy thing to diagnose 
an ulcer by its touch unless the finger is well trained; then only 
a slight roughness will be felt. With the speculum properly 
introduced the parts come into view and are made tense, and 
any fissure or ulcer that might be present must come into view. 
We prefer a simple bivalved speculum (see Fig. 6), which in 
shape resembles the index finger. In nearly every instance the 
ulcer will be located on the posterior surface and in the lower 
third of the rectum, frequently just above or within the grasp 
of the external sphincter, though in exceptional cases it may be 
found on any side and in any part of the rectum. When we 
have an intimation, from what the patient tells us, that the 
fissure is located on a certain side of the bowel, care should be 
used to make pressure against the opposite side with the spec- 
ulum or finger when introduced into the rectum, and by so 
doing much suffering can be avoided. Painful ulcers are 
usually single, though at times they are multiple. They will 
ordinarily appear as small cracks in the mucous membrane, 
which rarely ever extend through its entire depth unless the 
case is one of long standing. (See Plate VIII.) They are ex- 
ceedingly sensitive ; only slight pressure on them with the finger 
causes the most intense pain, which not infrequently lasts for a 
considerable time after the examination has been completed. 
As the external pile is the outer sentinel for an ulcer and its 
location, so we have an internal sentinel which does the same 
when the fissure is above the external sphincter. It is a teat, or 
polypoid-like growth, (see Plate IX), the end of which is always 
white and pointed. It readily presents itself when the speculum 
has been introduced, and at its base the ulcer will be located. 



> 



g 



en 



en 



pa 



CD 



> 



cz; 
en 




FISSURE AND PAINFUL ULCER. 119 

In cases of extensive ulceration these teats are sometimes very 
large, are multiple, and can be easily detected by digital and 
visual examination. After an ulcer has once been located, 
it should be probed to see if its edges are undermined and to 
find out if it has an internal, blind, fistulous opening concealed 
within it, for such a condition not infrequently is present. 

Diagnosis. 

In a very large percentage of persons afflicted with painful 
ulcers the diagnosis can be made with very little difficulty, 
though in an ordinary case the examination should be both 
visual and digital. In spite of this, many of these cases have 
been mistaken for other conditions by reputable physicians as 
well as by the laity. Amongst those diseases for which painful 
ulcer is most liable to be mistaken we will mention : — 

1. Hemorrhoids. 4. Blind internal fistula. 

2. Neuralgia of anus. 5. Disease of neighboring 

3. Spasmodic sphincteric con- organs. 

traction from any cause. 

Hemorrhoids. — We have treated many cases of painful 
ulcer of the rectum that had for months been treated for piles, 
when no tumor could be found. Such mistakes are the result 
of a superficial examination or of gross ignorance, for the two 
conditions are unlike in almost every respect. On inquiry of the 
patient as to the kind of an examination he had been given, he 
not infrequently answered my questions by saying that he told 
the doctor that he was suffering from piles, and that the doctor 
prescribed for him without making any examination whatever. 
This in part explains to us why persons suffer for years with 
painful ulcers, when they should have been well within three 
weeks, at the farthest, from the time when the treatment was 
begun. 

Neuralgia of the anus may be mistaken for painful ulcer. 
In fact, the symptoms of the two diseases are so similar that 
any one may get them confused unless a thorough examination 



120 DISEASES OF THE RECTUM AND ANUS. 

is made ; then the diagnosis can be cleared up beyond the 
possibility of a doubt, for, when the pain is due to neuralgia, it 
will be more general and the mucous membrane will be per- 
fectly healthy. On the other hand, when the suffering is due 
to painful ulcer, there will be a break in the mucous membrane. 
Such a rent is easily discernible, and when pressure is made at 
that point the pain will be very intense. 

Spasmodic sphincteric contraction, from whatever cause, is 
frequently mistaken for painful ulcer. We know this to be a 
fact, and have frequently seen it demonstrated by physicians 
who, in making an examination, would observe that the 
sphincter was tightly contracted and would almost invariably 
come to the conclusion that the patient had a fissure ; but 
further examination failed to reveal the presence of any rent in 
the mucous membrane. Not infrequently, in chronic constipa- 
tion, the sphincter takes on this spasmodic contraction, and, 
when it has continued for a considerable time, the muscles 
become hypertrophied. 

Blind internal fistula is quite likely to be mistaken for 
painful ulcer, especially when the opening is well within the 
sphincter ; sometimes both are present in the same case, and 
within the fissure may be hidden the fistulous opening. When 
a fistulous opening becomes very small or is obstructed, much 
acute pain and spasmodic irritation will ensue. At this junct- 
ure, unless a diligent search is made and the sinus located, the 
rase is quite likely to be diagnosed as painful ulcer and treated 
accordingly. This mistake subjects the patient to a long course 
of treatment, which fails in the end. A careful probing of any 
little rent or depression in the mucous membrane with a very 
fine probe will detect any fistulous sinus that might be present 
and prevent any such mistake. 

Disease of Neighboring Organs. — The reflex symptoms of 
a painful ulcer are many and varied, as a result of. pain re- 
flected to different organs in the pelvis. They are sometimes 
treated for some diseased condition when the real seat of disease 



FISSURE AND PAINFUL ULCER. 121 

is a small ulcer in the rectum. The relations existing- between 
the rectum, uterus, bladder, and prostate are very close ; and a 
study of the reflexes when one or the other of them is diseased 
is both important and interesting. 

Prognosis. 
Patients frequently ask if we can cure a painful ulcer. In 
reply to this question we can safely say that, if persons thus 
afflicted will place themselves in our hands and permit us to do 
with them as our judgment may direct, we can most certainly 
cure them, and in a few days or weeks at most. This reply, of 
course, has reference to uncomplicated cases only. If it should 
happen that the ulcer is only secondary to some other more 
serious disease, its cure will depend entirely upon the successful 
cure of the original disease. Unless the primary cause is first 
removed, even though we should succeed in curing the ulcer, it 
would, in all probability, return in a short time. Speaking in a 
general way, it may be said that the treatment of painful ulcer 
of the rectum will, in nearly every instance, be followed by 
speedy and gratifying results ; yet, when left to heal of its own 
accord, and when improperly treated, it may remain indefinitely 
and cause so much pain and nervous disturbance as to entirely 
incapacitate the sufferer for the discharge of his daily avoca- 
tions, while it sometimes makes complete nervous WTecks of 
women. They may even go from one physician to another and 
be treated for hysteria and other nervous phenomena. 

Treatment of Painful Ulcer or Fissure. 
Patients suffering from painful ulcer of the bowel do not 
consult their physician at the onset of the disease, but keep 
putting off going to the doctor from time to time for various 
reasons. Some think they will recover without medical aid and 
others do so because they dread an examination. It is very rare 
that a spontaneous cure takes place. As a rule, persons thus 
afflicted go on doing nothing or using some home remedies that 



122 DISEASES OF THE RECTUM AND ANUS. 

are said to have cured some neighbor until finally the pain 
becomes unbearable. The old saying, " a stitch in time saves 
nine." is applicable to the prevention and treatment of painful 
ulcer, for, when the surgeon's attention is called to a recent rent 
in the bowel, by ordering certain corrections of errors in habits 
and diet, together with cleanliness, it can be speedily cured. 
Knowing, as we do, that constipation, in a large percentage of 
the cases, is the direct cause, and when not the immediate cause 
that it is one of the symptoms, it at once becomes apparent that 
this condition must first be corrected, else the ulcer will not heal. 
For the relief of the constipated condition there are many things 
to take into consideration. First of all, highly-seasoned and 
stimulating foods should be discontinued and a thoroughly non- 
irritating diet substituted. Next, a daily movement of the 
bowel should be encouraged by the establishment of a regular 
time for going to stool ; and, if this is not sufficient, a mild 
laxative or some one of the cathartic mineral waters may be 
prescribed. Strong purgatives are not indicated and should 
never be prescribed, for they produce much tenesmus and 
straining ; and we have several times known them to start a 
diarrhea that was very difficult to manage. When the feces 
are impacted or become hard and nodular much suffering can 
be saved the patient by a copious enema of warm water and 
olive-oil or one of fiaxseed-tea, which does not leave any very 
unpleasant after-effect and prevents the long-continued after- 
pain that follows the expulsion of hard lumps of fecal matter. 
In giving enemata much care should be used in the selection of 
a syringe with a smooth nozzle, which should be greased with 
some stiff lubricant and introduced slowly into the bowel and 
pressed against the rectal wall opposite the ulcer. In order to 
avoid trouble and to cause very little pain, we have been in the 
habit of attaching a very large soft-rubber male catheter to the 
syringe. This can be introduced with ease, and does not irritate 
the parts. While undergoing treatment for painful ulcer, 
patients should be requested to take very little exercise and 



FISSURE AND PAINFUL ULCER. 123 

remain in the recumbent position as much as they can. The 
treatment of painful ulcer should be both palliative and opera- 
tive, depending upon the state of the ulcer at the time it is 
seen. 

PALLIATIVE TREATMENT. 

The palliative treatment, outside of the precautionary 
measures previously alluded to, consists principally in topical 
applications of various kinds applied judiciously. Almost any 
recent ulcer can be cured by such applications. It is not ad- 
visable to continue these applications for a long period, for if 
they are going to be of any benefit the improvement can be 
noted within two weeks ; and if there is not any in that time, 
operative interference is indicated. It is with gratification that 
we can say that a case of painful ulcer is, indeed, an exceptional 
one that does not get well after certain operative procedures, 
hereafter to be described, have been put into practice. Before 
using any application the fissure should be thoroughly cleansed 
with the peroxide of hydrogen or other antiseptic wash. Nitrate 
of silver 10 or 15 grains to distilled water 1 ounce we regard 
as the most useful application that we have. We have wit- 
nessed many cures from the use of this remedy, and it seldom 
requires to be applied more than half a dozen times, and in 
many cases not more than twice. Almost any of the astringent 
solutions will prove beneficial. The best ones are composed of 
zinc, lead, alum, the balsam of Peru, etc. In point of useful- 
ness, the balsam comes next to silver. It causes less pain and 
the results are very good, indeed. Certain powders, either dry 
or made up in the form of an ointment, often prove soothing 
and stimulate healing. The most useful are: hydrarg. chlor. 
mite, ferri sulph., salicylate soda, bismuth, subnit. and sub- 
iodide, and the stearate of zinc with iodoform, balsam, ichthyol, 
etc. Any of these applications will cause considerable pain 
when the ulcer is very sensitive. The pain can be alleviated to 
some extent by saturating a piece of cotton in a 6-per-cent. 
solution of cocaine and placing it over the ulcer for a short time 



124 DISEASES OF THE RECTUM AND ANUS. 

previous to the application. The ether spray will also prove a 
good anesthetic. Suppositories, as made by the average drug- 
gist, should be condemned so far as the treatment of painful 
ulcer is concerned. It matters not of what they are composed, 
for it has been our experience that they are either very soft and 
difficult to introduce through the firmly-contracted sphincter or 
they are so firm that, when introduced within the anus, they 
come in contact with the oversensitive ulcer and act as a foreign 
body. The pain thus produced is very severe, and continues 
until the suppository is absorbed or expelled. In the meantime, 
as increased spasm of the muscle is induced in its efforts to 
expel the foreign body, the following ointment will prove quite 
soothing and will tend to diminish sphincteric contraction and 
thereby lessen the pain : — 

R Morphinse sulphatis, .... gr. \ (0.0162 gramme). 

Ext. belladonna?, .... gr ss (0.0324 gramme). 

Vaselini, • 3j (4.00 c. cm.). 

M. Sig. : Apply at once and repeat. 

The following prescription is taken from Andrews.* We 
have used it in a number of cases and have always been well 
pleased with the results : — 

1J lodoformi, 3j ( 4.00c. cm). 

Ungt. belladonna, .... gss (15.00 grammes). 

Acidi carbolici, gr. x ( 0.65 gramme). 

Cosmolini, ^ss (15.00 grammes). 

M. Sig. : To be used daily. 

One of the best dusting-powders that we have used is 
composed of 

R Ilydrargyri chloridi mite, .... 5ij (8 grammes). 

Zinci stearatis cum balsami Peruviani, . 5ij (8 grammes). 

Sodii salicylates, Z] (4 grammes). 

M. Sig. : Dust over the ulcer daily. 

In fact, any remedy that will prove stimulating to the ulcer 
and soothing to the sphincter will be a good one in the treat- 
ment of painful ulcer of the rectum. 

♦Andrews, Rectal and Anal Surgery. Third edition, p. 152. 



FISSURE AND PAINFUL ULCER. 125 

OPERATIVE PROCEDURES. 

The following operative procedures have their respective 
adherents. Any one of them may prove serviceable when the 
other has failed to effect a cure : — 

1. Cauterization. 3. Division. 

2. Dilatation. 4. Excision. 

Cauterization. — Chemical caustics and the Paquelin cautery 
have both been commended and doubtless, in some instances, 
do much good. It has been our experience, however, that 
those cases which have resisted the treatment by astringents, 
cleanliness, etc., will do the same when cauterization is tried, 
and that many of them will not get well until rest of the 
sphincter is assured by either divulsion or incision. On the 
other hand, cases have been reported cured from the use of 
chemical caustics as well as the actual cautery. 

Dilatation. — Either forcible or gradual dilatation of the 
sphincter goes a long way toward relieving the pain and effect- 
ing a cure in cases where all palliative means have been tried 
and found wanting. Bodenhamer, for whose opinion we have 
the greatest respect, thinks that gradual dilatation with gradu- 
ated wax bougies is preferable to forcible divulsion of the 
muscle, and his results have been very good indeed. Most 
writers on the subject think that much time can be saved by 
immediate dilatation, and we concur in the latter belief. This 
can be done by first anesthetizing the patient ; then the two 
thumbs or index fingers are inserted into the bowel and sepa- 
rated, first in one direction and then in another, as far as pos- 
sible, care being used not to lacerate the mucous mem- 
brane nor tear the muscle. This should be practiced for five 
or ten minutes, when the anus will become patulous. The 
various mechanical dilators (see Figs. 53, 54) made for this 
purpose should be condemned, for they neither have eyes to see 
nor the sense of touch to guide them; consequently much harm 
may be done when they are used ere the operator is aware of it. 



126 



DISEASES OF THE RECTUM AND ANUS. 



When the fingers are used any tear will be immediately felt and 
the direction of the pressure can be changed. Divuhion of the 
muscles proves beneficial in two ways. In the first place, as a 
result of the divulsion, immediate rest is obtained and all spas- 
modic sphincteric contraction ceases; and, in the second place, 
the oversensitiveness disappears, supposedly as a result of stretch- 
ing the terminal nerve-filaments. In some cases an anesthetic 
will be contra-indicated. Then the dilatation can be effected 
gradually, and with comparatively little pain, by means of the 
hollow, graduated rubber bougies. (See Fig. 55.) It is better 
to commence with a small size, — say, a No. 8, — gradually 




Fig. 44.— Ideal Anal Dilators. (Half size.) 



increasing the size until a No. 12 can be easily introduced. 
It requires from ten days to two weeks to effectually dilate the 
sphincter by gradual dilatation. There is another form of 
rectal bougie that is used for dilating the sphincter muscles 
which is about two and one-half inches (6.4 centimetres) 
long, with a pointed knob on the end that causes it to be 
retained when grasped by the sphincter. (See Fig. 44.) They 
arc to be had in various sizes, but have no advantage over 
the ordinary rubber ones. When rest is once obtained, the 
sphincter requires only two or three applications of nitrate of 
silver or balsam of Peru to effect a permanent cure. 



FISSURE AND PAINFUL ULCER. 127 

Division. — M. Boyer was one of the earlier writers to ad- 
vocate incising the sphincter for the cure of painful ulcer. His 
method was to divide the entire muscle. Mr. Copeland was the 
first to teach us that a superficial cut made through the depth 
of the mucous membrane and possibly a few of the muscular 
fibres just beneath the ulcer would prove quite as effective as 
the method of M. Boyer. When the fissure is situated at the 
margin of the anus the incision can be made by separating the 
anus with the fingers of the left hand, while the cut is made 
with the knife in the other. If it should be higher up, any 
speculum that will expose the ulcer will be of great service. 
The object in division is to obtain rest and healing from the 
bottom. The cut can be made with any ordinary blunt-pointed 
bistoury, but should not extend through the entire muscle unless 
it is an u/nttsually bad case. A combination operation will 
prove valuable in some cases, — that is, after forcible dilatation 
the ulcer is incised. The danger of incontinence is naturally 

O ml 

less after partial than complete division of the muscle. 

Excision. — This operation is performed by making two 
elliptical incisions around the entire ulcer, through the mucous 
membrane. The diseased tissue is then removed. The edges 
of the wound left can be brought together with catgut sutures 
or left to heal by granulation. It will heal in a few days. This 
operation has no especial advantages over the method of in- 
cision, and, unless the sphincters have been previously divided, 
the results will not be so good. 

AFTER-TREATMEXT. 

The after-treatment is much the same as that practiced 
after operations for fistula, in that it is best to place a piece of 
lint in the bottom of the fistula to insure healing from the 
bottom. It will not be necessary for the bowel to be emptied 
for three or four days after the operation. Then, if it does not 
act of its own accord, a dose of salts or a Seidlitz powder, fol- 
lowed up by a copious injection, will bring about the desired 



128 DISEASES OF THE RECTUM AND ANUS. 

movement. There is no indication for any medicine to relieve 

pain, for when the sphincter lias been put to rest there will be 

very little pain. The ulcer should be cleansed daily with boiled, 

filtered water, peroxide of hydrogen, or other antiseptic solution, 

and touched up every three days with the nitrate of silver (gr. 

xv or xx to the ounce) or other astringent. This treatment and 

a few days' rest in bed will speedily and almost painlessly cure 

the most obstinate case of irritable fissure or ulcer about the 

anal margin. 

ILLUSTRATIVE CASES. 

Case XII. — Painful Ulcer from Constipation. 

J. C, aged 39, harness-maker by trade, came to my clinic, at the 
University Medical College, with the following history : He had been 
suffering from constipation of the worst form, induced by a sedentary 
occupation and irregular habits. He did not have more than one action 
a week, and then as a result of some strong cathartic. Some two weeks 
prior to the time he applied for treatment he had a very bountiful action. 
The feces were hard, irregular in shape, and very difficult to expel; so 
much so that when the}' were forced out he suffered from a severe tear- 
ing, burning pain that radiated toward the coccyx and lasted for two 
hours after the act had been completed. Considerable bleeding followed 
the expulsion of the last installment of feces. From then until the op- 
eration he had suffered the same severe pains and loss of blood every 
time he had an action, and in addition, for the last three days, the pain 
had been almost constant and was made more annoying as a result of 
the spasmodic contraction of the sphincter muscle. 

Examination revealed the presence of a well-marked fissure just 
within the grasp of the external sphincter; it was inflamed and exceed- 
ingly sensitive. 

Treatment. — Chloroform was administered, the sphincter was thor- 
oughly divulsed, and the ulcer was painted over with a solution of silver 
nitrate fifteen grains to the ounce. The rectum was cleansed daily with 
carbolized water and the silver used every three days for two weeks. At 
the end of this time the ulcer was completely healed. He was instructed 
to be regular in his habits and to keep the bowel open. He had no 
further trouble. 

Case XIII. — Patnful Ulcer with Bladder Complications. 
Mrs. C, aged 27, was referred to me from the countiy. She com- 
plained of some pain in the rectum and said she was positive that some- 



FISSURE AND PAINFUL ULCER. 129 

thing was wrong with the bladder, for she had a desire to urinate almost 
all the time. A careful examination of the bladder and the urethra was 
made, and the}' seemed perfectly healthy. The urine was examined and 
nothing of a suspicious nature was found. Next I turned my attention 
to the rectum, and there, one inch (2.54 centimetres) above the anus, on 
the posterior wall, an irritable ulcer, about the size of a split pea, w r as 
located, which proved to be the source of irritation. We know this be- 
cause the ulcer was incised through the centre deep down into the mus- 
cle. By the aid of cleanliness and a few applications of the balsam of 
Peru it soon healed and, as it did so, all the bladder symptoms disap- 
peared and never returned. I mention this case simply to show one of 
the reflex phenomena of painful ulcer or fissure. 

Case XIV. — Painful Ulcer within External Pile. 
Mr. H., a prominent judge of our city, came to me suffering from 
complete nervous prostration. He was totalty unfit to occup3 T the bench. 
He informed me that he was suffering from some exceedingly painful 
disease of the rectum, which he feared might be cancer, his mother hav- 
ing died with cancer of the breast. On examination an ulcer was found 
hidden almost from view within the folds of an external pile. No other 
pathological condition was found. He would not consent to take an 
anesthetic; so a solution of cocaine was applied on cotton for a short 
time and a No. 10 soft-rubber bougie introduced and left until the 
sphincter relaxed sufficiently to admit the speculum. Then the silver 
solution was applied. The treatment had to be repeated but four times 
before he was well and returned to his usual duties, free from pain, and 
in a short time his nervous system was restored to ti normal condition. 



CHAPTER XIV. 
ULCERATION. 

Having written of painful ulcer in the previous chapter, it 
is our intention now to consider all other forms of rectal ulcer- 
ation, except those due to cancer, which will receive full con- 
sideration in Mr. Herhert AUingham's excellent chapter on rectal 
cancer. Rectal ulceration is said to occur more frequently in 
women than men, due to pressure of the child's head on the 
rectum during childbirth and from the fact that women are 
more apt to be constipated. This has not been our experience, 
for we have seen ulceration occur in men as frequently as in 
women. We do believe that the ulceration is inclined to be 
more extensive in women, due probably to constipation. Chil- 
dren rarely suffer from other than painful ulcer except when 
they are suffering from chronic diarrhea. The ulceration may 
present itself in a variety of ways : it may be slight or extensive, 
deep or shallow. Again, the characteristics of the ulcer may 
be marked. In one case it will be what we term a live ulcer. 
By this we mean one in which the base and edges are red and 
well defined, but have a healthy look and are quite sensitive to 
the touch. In another case the ulcer may be dead, as it were ; 
it is large and cup-shaped ; the edges are not sharply defined, 
but have a rounded, glistening, indurated appearance, and when 
it is touched is almost entirely devoid of pain, and in all prob- 
ability has been there for a long time. There are a great many 
causes of rectal ulceration, some of which are mechanical and 
others specific. The following classification includes the usual 
forms of rectal ulceration that one is likely to meet : — 

1. Traumatic. 4. Tubercular. 

2. Syphilitic. 5. Catarrhal. 

3. Dysenteric. 6. Rodent. 

(130) 




PLATE IX.- ULCERATION AND POLYPOID-LIKE SENTINEL TEATS. 






ULCERATION. 131 

Traumatic. — Traumatic ulceration may be the result of an 
injury done to the rectum from a variety of causes, among 
which constipation takes the lead. It usually produces the 
injury in one of two ways. In the first place, when the bowels 
have not acted for a long time, the fecal matter collects in large, 
hard, nodular lumps, which require considerable force to expel. 
As a result of great straining the mucous membrane is stretched 
to its fullest capacity, and is quite frequently lacerated or bruised. 
In the second place the injury is not a result of the expulsion 
of the fecal mass, but is due to a large impacted mass which 
presses the rectum back against the bony structures and injures 
it or by the pressure interferes with the circulation, frequently 
causing the tissues at the points of pressure to become necrosed 
and to die. Surgical operations for the cure of piles, polypi, 
etc., when healing is delayed, often cause ulceration. It may 
be caused by pressure upon the rectum as the result of a preg- 
nant or diseased uterus, enlarged prostate gland, or a tumor of 
any kind. Foreign bodies that have been swallowed or intro- 
duced within the rectum may cause ulceration, — such as fish- 
bones, pins, false teeth, etc. Occasionally the parts get bruised 
from a fall or kick. At another time the ulceration will be due 
to a ruptured vein or a pile that has sloughed off, or from the 
lodgment of a small seed in the little depression to be found in 
the mucous membrane. 

Syphilitic. — It is our intention to refer to syphilitic ulcera- 
tion in this chapter in a general way only, for it will be referred 
to again in the chapter on syphilitic affections of the rectum and 
anus. It may be congenital and make its appearance about the 
anus and lower part of the rectum two or three months after 
birth ; this we have frequently observed in dispensary practice. 
Again, syphilitic ulcers may make their appearance at the same 
time that the mucous patches are to be observed in the mouth ; 
but the worst form of syphilitic ulceration of the rectum does 
not occur until the tertiary stage, when it may be present in 
large, irregular patches, as a result of one or more gummata's 



132 DISEASES OF THE RECTUM AND ANUS. 

breaking down. This last form of ulceration we see almost 
daily in private and dispensary practice, and it seems to be more 
prevalent among negroes than whites; but this is easy for those 
to understand who are acquainted with the loose habits of the 
colored race. This latter form almost invariably terminates in 
a tight stricture. Ordinarily the diagnosis can be made with 
little difficulty when due attention has been given to the study 
of the previous history and the symptoms that present them- 
selves at the time the examination is made. - 

Dysenteric. — Dysenteric ulceration is recognized by nearly 
all writers on this subject as being a frequent cause of rectal 
ulceration. That dysentery causes this condition cannot be 
doubted, but we are of the opinion that ulceration from this 
cause is not of frequent occurrence (at least in this country), for 
we have seen a great number of cases of ulceration from all 
causes except dysentery. We have only seen two cases where 
we were satisfied that ulceration was a direct result of a true 
dysentery. At the same time, we can readily understand why 
it is put dow 7 n as a more frequent cause in those countries 
where the climate is warm and dysentery is known to prevail. 
So-called chronic dysentery (diarrhea) we know is a frequent 
cause of rectal ulceration, for we have, time and again, seen an 
ulceration disappear after the diarrhea had been arrested. It is 
a well-known fact that any irritant discharge that is being con- 
stantly secreted or retained in the rectum will irritate the mucous 
membrane and cause ulcers to form. We do not wish to leave 
the impression that diarrhea always precedes and causes ulcer- 
ation, for such is not the case. It is not an uncommon thing to 
see a chronic diarrhea relieved by curing an ulcer in the rectum ; 
in fact, diarrhea may produce ulcers and ulcers may cause diar- 
rhea. We will speak more fully of the relation of ulceration to 
chronic diarrhea in another chapter. Ulceration when due to 
true dysentery is markedly progressive, and there is a great loss 
of tissue ; and when healing does take place, it is nearly always 
followed by more or less contraction. 



ULCERATION. 133 

Tubercular ulceration is quite common, especially in those 
persons who are predisposed to phthisis. Tubercular ulceration 
presents itself in two forms : 1. As a simple ulceration in those 
suffering from general tuberculosis. 2. Ulceration due to 
breaking clown of localized tubercular nodules. All who have 
treated many cases of rectal ulceration, surely, have noticed these 
two conditions. In the first variety there is not any indication 
of the tubercular nodules in the rectum ; but a simple rectal 
ulceration, from whatever cause, which is slow to heal on account 
of the debilitated condition of the patient as a result of the lung 
complication. This form, however, may be benefited by an im- 
provement of the patient's general health and the removal of 
any local irritation. In the second variety, or real tubercular 
ulceration, we have the local deposits of the tubercular nodules, 
which may be single, but which, as a rule, are deposited in mul- 
tiple patches about the rectum, which after a time break down 
and ulcerate, leaving an ulcer with irregular edges, grayish in 
appearance, which has not the slightest tendency to heal unless 
vigorously treated. When an ulcer is formed, it seems to be 
the signal for the other deposits to break down and coalesce, 
until the whole rectum is encircled by an irregular band of ulcer- 
ation, which has a grayish, glistening appearance, which does 
not secrete true pus, but a kind of thin, watery fluid. Under 
ordinary circumstances the ulceration does not improve, but con- 
tinues to get worse until life is a burden or death finally relieves 
the patient of 1 lis sufferings. When there is a tendency toward 
healing, it is followed by a contraction and a stricture. W r e do 
not know of any other class of sufferers that are more deserving 
of sympathy than those just referred to. There is another form 
of ulceration, termed lupoid, spoken of by Van Buren,* which 
he believes is a result of the bad habits of women of tubercular 
constitutions, upon whom syphilis has been ingrafted. 

Catarrhal. — It will be remembered that we spoke of a 
catarrhal condition due to proctitis, in another chapter, which 

* Van Buren, Diseases of the Rectum, p. 232. 



134 DISEASES OF THE RECTUM AND ANUS. 

induced a diarrhea and an abundant discharge of mucus. The 
mucus, from its constant passing over the mucous membrane 
and from its being- retained in the lower part of the rectum, 
causes an irritation of the membrane and, frequently, a sur- 
prising loss of tissue. The ulceration thus made is not allowed 
to heal, but is constantly being aggravated and made worse by 
the straining and the passing over it of fecal matter that fills 
every crevice and retards healing. The ulceration in this case 
is secondary to the inflammation and will not get well until the 
proctitis is first relieved. 

Rodent. — This form of rectal ulceration is exceedingly rare 
and it is well that such is the case, for it induces very great 
suffering. It is often confused with cancer of the rectum or 
tubercular ulceration, owing to the severe pain, amount of 
tissue destroyed, and its tendency to break out again and again, 
and its gradual increasing in spite of all treatment. Young 
and old are alike subject to it. It is not always rapid in its 
course ; patients may live for years while the ulceration grad- 
ually extends itself, until finally death comes as a result of 
hemorrhage or from diarrhea and exhaustion. It usually 
attacks the lower part of the rectum at the juncture of the 
mucous membrane and skin. It is a superficial ulceration and 
the discharge creeping from it contains very little pus and is 
composed principally of serum. Mr. Cripps* places on record 
a case, reported by Dr. McDonald,")" which illustrates how great 
the loss of tissue may be. On the hips, just beyond the ischial 
tuberosities, were long scars of healed ulcers, thin and bluish. 
The entire ano-perineal region was gone, there being a hollow 
space as big as a fetal head. The urethra was entire, as well as 
the mucous membrane between it and the cervix, which was 
healthy. The anus, rectum, and vagina, other than the anterior 
portion, were gone, the bowel opening by a tight aperture 
behind the cervix. The patient could not keep clean, except 

* Diseases of the Rectum and Anus, p. 208. 
f Edinburgh Medical Journal, April, 1884. 



ULCERATION". 135 

when the feces were liquid. In this fearful condition she per- 
formed her household duties. Finally the ulceration extended 
upward into the pelvis, leaving the bowel hanging- loose for 
some distance from the upper level of the ulceration, giving 
it the appearance of a torn coat-sleeve. After several years' 
suffering she died of diarrhea and exhaustion. 

Symptoms. 
The more prominent symptoms of rectal ulceration are 
five in number : — 

1. Diarrhea. 4. Discharges of pus 

2. Pain. and mucus. 

3. Hemorrhage. 5. Itching. 

Diarrhea. — Rectal ulceration never becomes extensive 
without causing diarrhea to a greater or less degree. Usually 
this is the most prominent symptom and the patient comes to 
be treated for this, not knowing that it is caused by the 
ulceration. The stools may vary from three to twenty a day, 
accompanied by great straining and tenesmus, which are very 
exhausting and cause the patient to decrease rapidly in weight. 
We have under observation at the present time a gentleman 
who has been suffering from ulceration for one year. At the 
beginning of his illness he weighed two hundred and forty 
pounds ; at the present time he only weighs one hundred. The 
frequent stools are brought about as a result of the feces coming 
in contact with the exposed nerve-filaments, which results in 
increased peristalsis. The symptoms in many respects resemble 
those of dysentery, for which it has been mistaken. 

Pain. — Pain in ulcerations was referred to in the chapter 
on the general symptomatology of rectal disease, but not in de- 
tail. Persons suffering from ulceration may have very little or 
a very great amount of pain. It is a common thing for those 
suffering from extensive ulceration not to complain of pain, es- 
pecially if the ulceration is situated high up in the rectum. In 
others, where the ulceration is situated low down, near the anal 



136 DISEASES OF THE RECTUM AND ANUS. 

margin, it may be very intense, though the ulcer is quite small. 
It appears that the sensibility varies in different portions of the 
rectum, the upper part being much less sensitive than the lower. 
In fact, the sensibility increases from above downward, and this 
explains why the pain is so great in a painful ulcer situated on 
the anal margin, when the lesion is small and out of all propor- 
tion to the amount of suffering. The pain may be constant or 
intermittent ; it is usually severe during and immediately after 
stool. In the interval there may be a dull aching, which may 
be confined to the rectum or extended up the back or down the 
limbs ; in fact, the reflex symptoms in cases of ulceration are 
multiple, and they are sometimes so marked as to lead one to 
believe there is a diseased condition of the bladder, prostate, 
uterus, tubes, or ovaries. We have in one case located and 
cured a rectal ulcer that caused constant pain in the pelvis, for 
the relief of which both ovaries had been removed without 
giving the slightest benefit. From this and other cases we have 
treated, it seems to us that the tubes and ovaries are not to 
blame for all the pains produced in the pelvis, but that ulcer- 
ation of the rectum not infrequently plays an important part, 
and should not be overlooked, but searched for carefully when 
pains are present in the pelvis which cannot be accounted for in 
any other way. 

Hemorrhage. — Hemorrhage is always present in a greater 
or less degree, depending upon the location and extent of the 
ulceration. It may be so slight that the discharges are tinted 
with it, or, perhaps, a slight streak may be seen on one side of 
the fecal mass. In another case, when the ulceration has eaten 
deeply into the tissues and into some artery or vein, the bleed- 
ing may be very profuse, and large quantities may be lost before 
it will stop or can be averted. We have seen this occur to such 
an extent that the patient fainted from the loss of blood ; others 
have reported cases that terminated fatally as a result of such 
hemorrhages. Ordinarily, there will be more or less bleeding 
after every stool, for the passage of the fecal mass over the raw 



ULCERATION. 137 

surface scrapes off any little plug that might have occupied the 
rent in the vessel, and the bleeding starts anew. When it 
becomes mixed with the contents of the rectum it forms a dark- 
brown, semisolid mass, which closely resembles coffee-grounds. 

Discharges. — Besides the blood, there will be discharges 
of pus and mucus in varying quantities. When the ulceration 
is slight they will be small, but increase in proportion as the 
ulceration extends itself. Such a discharge is constantly found 
seeping out at the anus, the margins of which will be glued 
together ; it is sticky, reddish in color, of the consistence of pus, 
with here and there a piece of necrosed tissue. 

Itching. — In cases of long standing there will almost in- 
variably be a pruritus about the anal margin, and this may 
extend in any direction, until many deep fissures are to be seen. 
This condition is produced by the irritating discharges that are 
constantly oozing out, and it usually subsides when the ulcer- 
ation has been cured. 

Other Symptoms. 

When the ulceration is extensive and chronic, the patient 
will be subjected to attacks of peritonitis that may cause intes- 
tinal adhesions to a greater or less extent. This fact has been re- 
peatedly demonstrated on the post-mortem table. In case there 
is not a free exit for the discharge, it will burrow and form an 
abscess and fistula will follow. Where the ulceration is exten- 
sive, as healing takes place, a certain amount of contraction 
must unavoidably follow. As the ulceration encroaches upon 
the anus, both sphincters may be destroyed ; the anus becomes 
patulous and is surrounded by a broad, dark ring, with several 
club-shaped tags of skin hanging about the margins. These 
tags, discolored skin, and the patulous condition of the sphincter 
are always indicative of serious rectal disease. 

Diagnosis. 
The diagnosis is not difficult to make if ordinary care is 
displayed in getting the history and in making the examination 



138 DISEASES OF THE RECTUM AND ANUS. 

with the appliances at our command. When the ulceration is 
at all extensive a diagnosis can be made with the linger. If it 
is slight, by the aid of a hinged speculum all sides of the bowel 
can be separately examined and the ulcer located without causing 
much pain. It is not a difficult thing to diagnose rectal ulcer- 
ation, but it is not always so easy to tell its character ', unless it 
be of the traumatic variety. 

Prognosis. 

A great many general practitioners look upon an ulcera- 
tion of the rectum as being a comparatively trivial matter, and 
think it easy to cure. Just here we wish to correct this impres- 
sion and to say that there is scarcely any other surgical disease 
that requires more persistence and scientific skill to effect a cure 
than rectal ulceration. It is true that the traumatic variety 
easily succumbs to simple treatment ; yet many of the cases of 
chronic ulceration, such as tubercular, syphilitic, cancerous, and 
dysenteric, frequently go on from bad to worse in spite of all 
treatment, until a stricture is formed, perforation of the bowel 
occurs, or the patient dies from exhaustion, as a result of the 
constant diarrhea and hemorrhage. It is best to inform these 
sufferers that we can from the start relieve their suffering: in 
part, but, if they wish to receive any permanent benefit, they 
must prepare themselves to follow out all instructions to the 
letter, and they must submit to treatment for several weeks or 
months. 

Treatment. 

The treatment is divided into two classes: — 

1. Palliative. 2. Surgical. 

PALLIATIVE TREATMENT. 

It is at once obvious that the treatment of rectal ulceration 
must be varied, depending not only upon the extent of the 
ulceration, but upon the initial cause. For instance, one would 
not think of giving the same treatment in a simple traumatic 



ULCERATION. 139 

ulceration that would be given for an ulceration due to syphilis. 
The treatment of rectal ulceration is far more serious than that 
of a painful ulcer at the anal margin. The most prominent 
feature in the treatment of extensive ulceration from any cause 
is rest. When we say rest we do not mean that the patient is 
to lie down a few moments and then go about her household 
duties, but that she must go to bed and stay there for weeks and 
sometimes months, and give nature a chance. Rest acts as does 
a splint, and prevents venous congestion of the rectum, — a con- 
dition that is certain to occur in the erect posture. The result 
obtained is similar to that when we treat an ulceration of the 
limb by elevating it and supporting the superficial vessels with 
adhesive straps or for varicose veins of the extremities. We 
must now endeavor to assist nature to build up the tissues by 
both local stimulants and constitutional remedies. If the pa- 
tient is debilitated, tonics are indicated ; codliver-oil, iron, malt 
preparations, beef-juice, etc., will be found useful. For diarrhea 
many remedies have been suggested and stood the test for a 
time. As a rule, however, the good effect of any medicine 
wears off after a time and a new one has to be substituted. 
Vegetable astringents are very good, combined with opiates, to 
prevent tenesmus and straining. We have seen the number of 
stools diminish after a few doses of tannic or gallic acid. 
Preparations of starch, bismuth, magnesia, and chalk are all 
good in some cases. Morphine and pulverized opium relieve 
the pain and diminish peristalsis. They must be used very 
cautiously, for ulceration is very often a chronic disease ; and 
if patients commence using these drugs it is very difficult, 
indeed, to get along without them, and when the ulceration is 
healed they are apt to keep up the habit. 

Diet. — The diet should be simple and non-irritating and 
liquid, so far as practicable. All highly-seasoned foods, pastries, 
tobacco, and all alcoholic stimulants should be discouraged and a 
milk diet substituted. Some patients will recover with no other 
treatment than rest and the correction of certain errors in diet. 



HO 



DISEASES OF THE RECTUM AND ANUS. 



Local Treatment. — The local treatment varies, and will 



require changing from time to time. The one 



thing essential 



is to keep the rectum thoroughly clean. This is best done by 
copious injections of warm water and Castile soap or carbolized 
water, at least twice a day, and more frequently where the 
ulceration is extensive and forms pockets in which pus may 
accumulate. When pus is allowed to accumulate it will bur- 




Fig. 4o.— Insufflator. 



row, an abscess will form, and a fistula will be the result. This 
we have frequently seen. Weak solutions of bichloride are 
good, — say, one part to five or six thousand ; it is not well to use 
them much stronger, else vomiting and tenesmus will follow. 
After the bowel has been cleaned out, a mixture, composed of 
balsam of Peru half an ounce, glycerin one ounce to four of 
water, well mixed, proves both soothing and healing. The bal- 
sam alone mopped over the ulcerated surface is one of the best 
stimulants we know of. Copious injections of nitrate of silver, 




Fig. 46.— Allingliam's Ointment Applicator. 

twenty-five grains to three pints of water, injected twice a week, 
will be followed by marked improvement. When applied 
directly to the ulcer, it may be used as strong as twenty grains 
to the ounce. Fuming nitric acid has been highly recommended 
as well. Suppositories of opium, belladonna, etc., are some- 
times serviceable. We rarely ever use them for the reason that 
when they are introduced they cause more or less pain and 



ULCERATION. 



141 



straining. Dusting-powders introduced by an insufflator (see 
Fig. 45) and ointments used in the ointment applicator (see Fig. 
46) both are useful. The best medicines to use, either as pow- 
ders or ointments, are the astringents, — lead, zinc, alum, calo- 
mel, bismuth, subnit. and subiodide, stearate of zinc with balsam 
or menthol, and iodoform. To allay any irritation a solution 
of cocaine, fifteen or twenty grains to the ounce, will do as well 
as any. When the ulceration is due to syphilis the patient 
must undergo the ordinary treatment given for syphilis in 
addition to the local medication. (See chapter on " Syphilitic 
Affections of the Rectum and Anus.") 




Fig. 47. — Sinis's Irrigator and Drainage-Tube. 



SURGICAL TREATMENT. 

When the ulceration is a simple one and of traumatic 
origin, it can be easily and quickly cured by a thorough divul- 
sion of the sphincters, to be followed by two or three applica- 
tions of solution of silver. This we have demonstrated many 
times both in private and hospital practice. If ulceration be 
due to syphilis, dysentery, or tuberculosis, this treatment will 
not be sufficient. In addition, it is necessary to thoroughly 
curette the ulcers down to the healthy tissue ; then apply some 
stimulant or caustic, irrigate the rectum, and place the patient 
in bed. Division of the base of the ulcer including the sphinc- 
ter will insure rest. Many prefer this to divulsion. When 



142 DISEASES OF THE RECTUM AND ANUS. 

there is a single ulcer that is not too large or does not extend 
through the mucous membrane, it may be removed by in- 
cluding it in two elliptical incisons when the edges are brought 
together with catgut sutures. After such an operation, if a dry 
dressing can be placed and retained over the cut for a few hours 
it will be a success ; otherwise, it will prove a failure. The 
injection of astringent fluids into the base of an ulcer does not 
have any advantages over ordinary medications. 

In those cases which keep on getting worse and worse, 
when the pain is most intense and the diarrhea is so bad that 
it keeps the sufferer in the closet almost half his time in spite 
of all local and constitutional treatment, there is only one thing- 
left to do, and that is to perform colotomy, which will be 
thoroughly described by Mr. Allingham in his chapter on this 
subject. Colotomy, when performed as it should be, gives im- 
mediate relief and all the tenesmus is done away with. It gives 
us an opportunity for flushing the entire rectum and sigmoid 
from above and below, and enables us to apply the medications 
directly to the seat of the ulceration. In this way many cases 
that would otherwise be incurable can be cured, after whir 1 ! the 
opening can be closed or left open. Many patients who have 
had colotomy performed object to having the opening closed on 
account of the necessity of undergoing another operation, or 
through fear that the ulceration may return. The relief is so 
great and the inconvenience caused by the artificial anus is so 
slight that they do not care to take any chances of having the 
pain and tenesmus return. We speak of those who have had 
a left inguinal colotomy ; for, after this operation, patients can 
dress themselves, wear a truss, and attend to their ordinary 
duties. The disgust to colotomies that existed in former years 
is fast, and very properly, dying out, for the condition of per- 
sons after inguinal colotomy is not nearly so deplorable as many 
who have never seen the operation would believe. 



ULCERATION. 143 

ILLUSTRATIVE CASES. 
Case XT. — Ulceration of the Rectum. 

A banker, aged 41, a slender man. of pallid countenance, suffering 
from some rectal trouble, consulted me in the latter part of December. 
1892. He stated that he had considerable pain every time he had an 
action; and, further, that at times there was more or less bleeding and 
always some pus ; the latter was usually of a brick dust color. He suf- 
fered intense pain almost constantly when on his feet. Now and then 
it would be reflected up the back and down his legs. Of late he had 
been much annoyed by an unpleasant sensation in the lower portion of 
the rectum, as if the bowel were going to act, The stools were frequent 
and accompanied by griping and tenesmus. I carefully examined into his 
general health and found it all that could be desired. He assured me 
that if I could correct his rectal disease lie would be all right. The 
sphincter being very tight. I advised him to take an anesthetic, that a 
thorough examination might be made, and told him that if a surgical 
operation were necessary it would be performed while he was unconscious. 
A Cook speculum was inserted well up the bowel after the sphincter 
had been divulsed. and by the aid of a good light an ulcer as large as a 
silver half-dollar was located on the posterior wall of the rectum, a little 
to the right of the median line, two and one-half inches (6.4 centimetres) 
above the anus, the edges of which were rounded, raised, and very hard ; 
all of which demonstrated the fact that it had been there for many weeks, 
if not months. On either side of it were two white polypoid growths 
about half an inch (1.3 centimetres) long. (See Plate IX.) The mu- 
cous membrane below the ulcer was somewhat excoriated, as also was 
the anal margin, because of the acrid discharge that was passing over 
them. 

Treatment. — The ulcer and the immediate vicinity were curetted 
thoroughly and then incised. We next paid our respects to the external 
sphincter and severed it. because of its tonic contraction. The bowel was 
irrigated with a solution of carbolic acid and a piece of gauze inserted 
to insure drainage and to warn us in case of hemorrhage. The patient 
was then placed in bed and surrounded by hot bottles. Thirty-six hours 
afterward the gauze was removed, the rectum irrigated, and the ulcer 
dusted over with calomel, which, by the way. is a valuable remedial agent 
in starting healthy granulations in almost any chronic sore. A fluid and 
semisolid diet — which consisted principally of milk, soft-boiled eggs, and 
strong soups — was ordered. The bowels were moved every second day. 
by aid of mild cathartic mineral waters. He was not allowed to get out 
of bed or sit up for three weeks. During this time the ulcer was 



144: DISEASES OF THE RECTUM AND ANUS. 

cleansed, ami either a solution of silver, the balsam of Peru, or calomel 
was applied every other day. By this time the diarrhea had stopped ; 
he was free from pain and had gained twenty pounds in weight. The 
local applications were continued for three weeks longer, when the ulcer 
had entirely healed. He was then discharged, with instructions to return 
to the cit} r immediately should he ever feel any uneasiness about the 
rectum. It has now been two years since I saw him last, but I have 
heard that he is perfectly well. 

Case XVI. — Ulceration of the Rectum. 

About one year ago the first of this month I was requested to visit 
a 3'oung lady at a boarding-school ; she was suffering from some rectal 
disorder. The principal informed me that she had been very despondent 
of late and had frequently remarked that if she did not get relief soon 
she would commit suicide. On questioning her I learned that she was 
of an exceedingly nervous temperament, and that six months previously 
she had a diarrhea that lasted for three weeks, when suddenly it ceased 
and she became markedly constipated instead. Up to this time she had 
no pain except the tenesmus that accompanied the frequent stools ; 
reeentty, however, she was seldom without pain. When asked where it 
was located she placed her hand over the coccyx and sacrum and said it 
was there most of the time, but now and then over the ovaries. She 
suffered most, however, during and for about one hour after defecation. 
The pain was so severe at times that she almost went into spasms. She 
menstruated regularly and there was no indication of bladder or kidney 
trouble. She finally consented to a digital examination, provided I 
would give her chloroform and do what was required at the same time. 

Examination revealed three ulcers, about the size of a silver dime, 
at the upper edge of the internal sphincter. They were highly inflamed 
and so was the rectal wall in the immediate vicinity. The sphincter 
muscles were stretched first in one direction and then in another until 
the3 r were passive ; the ulcers were then painted over with nitric acid, 
care being used not to get any on the healthy bowel. Since the edges 
of the ulcers were not thickened nor indurated, and the muscles were not 
hypertrophied, it was not thought advisable to incise either. The after- 
treatment consisted in keeping her in the recumbent position, the diet 
was restricted to liquids and semisolid foods, and the bowels were 
moved gently eveiy other day. In the meantime the rectum was irri- 
gated daily with carbolized water, while a mild astringent was applied to 
the ulcer every other day. This plan of treatment was continued for 
only two weeks, when the ulcers were completely healed and all the local 
symptoms had disappeared. Her school-girl friends said that she was 



ULCERATION. 145 

like her old self again and as jolly as any of them. Three months after 
she was discharged she wrote me that she was perfectly well. I think 
that I never treated any one who was more grateful for services 
rendered. 

Case XVII. — Tubercular Ulceration. 

A lady, aged 31, was referred to me by a physician from a neigh- 
boring town, with the following history : She had inherited a phthisical 
constitution from her mother and had alwa}^s been very delicate. One 
year previous to the time I saw her she caught a cold and had been 
bothered with a A^ery annoying cough ever since. She had night-sweats, 
which weakened her very much. In addition to this she was suffering 
from a rectal trouble that caused much pain, and she had frequent stools 
that were mixed with a thin, glairy -looking pus with a foul odor. 

Examination revealed a patulous anus. The speculum was inserted 
without the slightest pain and a deep ulcer with irregular edges was 
located just within the external sphincter, which was almost eaten 
through ; this, in part, accounted for the patulous appearance of the 
anus. 

Treatment. — On account of the lung complication it was deemed 
advisable not to give an anesthetic, but to cocainize the parts, to curette 
and apply nitric acid to the ulcer, and not to incise the sphincter, for in 
such cases too much cutting may result in incontinence. Tonics and a 
strong diet were prescribed ; she was also requested to spend most of 
her time in the open air in the sunshine. This, together with the local 
application of mild astringents, constituted the treatment. It required 
nearly three months for the ulcer to heal, owing to the debilitated con- 
dition of the patient. She was never bothered again with the ulceration, 
but she died, some eighteen months after she left the hospital, from the 

old luno- trouble. 

10 



CHAPTER XV. 



BENIGN STRICTURE. 



A stricture of the rectum is a narrowing of the gut ; it 
may result from contraction or from mechanical pressure out- 
side of the bowel, caused by an enlarged prostate, a dislocated 
uterus, or a tumor. In one case the 
contraction will be very limited, not 
being more than one-half inch (1.27 





Vis;. 48.— Diagrammatic Drawing of 
Annular Stricture. 



^ 10) 



Fig. 49.— Diagrammatic Drawing of 
Tubular Stricture. 



centimetres) in breadth (annular, see Fig. 48), while in another 
it will be broad and may involve two or three inches (5 or 7.6 cen- 
timetres) of the bowel or more (tubular, see Fig. 49). On close 
examination the mucous membrane, as well as the submucous 
(146) 



BENIGN STRICTURE. 147 

tissue, will appear rough, thickened, and indurated, as a result of 
the chronic congestion and infiltration. A stricture may or may 
not entirely obstruct the calibre of the bowel. When the bowel 
is entirely occluded it is called complete. When all or a part 
of the fecal matter can escape through the stricture it is a par- 
tial stricture. There are many kinds of strictures, when classi- 
fied from an etiological stand-point, which seems to us the most 
rational way of classifying them ; though some high in authority 
do so according to the shape of the constriction and the amount 
of the bowel involved, designating them annular, tubular, cres- 
centic, etc. Knowing as we do that a very large percentage of 
all strictures is due either to inflammatory deposits or cicatri- 
zation following some one of the various forms of ulceration, as 
described in the previous chapter, we shall base our classification 
upon these facts, and give the same classification for stricture 
that we did for ulceration, considering each in detail ; then we 
shall pay our respects to some other varieties of stricture as 
given by other writers on this subject. The following classifi- 
cation will include all the different kinds of stricture likely to 
be met with in the rectum. We have purposely omitted can- 
cerous stricture, for Mr. Allingham will deal with this variety 
in his chapter on cancer : — 

1. Traumatic. 3. Tubercular. 

2. Syphilitic. 4. Catarrhal. 

5. Dy sent eric. 

General Remarks. 

Stricture of the rectum is usually located in the lower por- 
tion, though no part of the colon or rectum is exempt. The 
location may vary somewhat, but in the majority of cases it will 
be within two and one-half inches (6.4 centimetres) of the muco- 
cutaneous junction. Stricture is rarely ever found in the young ; 
only a few cases have been reported in young children. We 
treated one case, that of a colored girl, aged 13, due to syphilis. 
It is the exception to see a case of stricture in a person under 



148 



DISEASES OF THE RECTUM AND ANUS. 



30 years old. Women are mueh more prone to this disease 
than men. One reason is on account of their being more sub- 
ject to constipation. 

Traumatic. 
All writers agree that traumatism is a frequent cause of 
stricture in the rectum as well as in other portions of the ali- 
mentary canal. The injury that is directly or indirectly respon- 
sible for the stricture may be slight or extensive, the result of a 
blow from the outside or from pressure of some internal organ ; 
it may cause diminution in the calibre of the bowel by obstruct- 
ing one side of the rectal wall, or the whole circumference may 
be involved. The constriction in exceptional cases may occur 




Fig. 50.— Appearance of a Cross-Section of Strictured Rectum. 

suddenly ; as a general thing, however, a constriction comes on 
gradually, as a result of some wound or ulceration that refuses 



The following are some of the more common causes 



to heal. 

of traumatic stricture 



1. Surgical operations. 

2. Constipation and fecal impaction. 

3. Introduction of foreign bodies, accidental^ or otherwise. 

Surgical Operations. — We have no doubt that surgical 
operations frequently cause rectal stricture, for we have seen 
and treated several cases where the stricture was directly trace- 
able to this cause. We desire to say, in justification of this 



BENIGN STRICTURE. 149 

statement, that nearly all of these cases had been operated on 
by some one of the numerous ignorant itinerants and orificial 
surgeons that infest this portion of the country, It has been 
our good fortune never to have a well-marked stricture follow 
any operation. In one instance there was some constriction, 
which was easily remedied, caused by the removal of several cuta- 
neous tags and piles. The constrictions following- the operation 
by the itinerants were, in a large percentage of the cases, due 
to sloughing and ulceration, following the injection of different 
solutions into pile-tumors. After an operation the patient is 
told to go about his ordinary duties, and no attention is paid 
to the ulceration. In some instances it may get well, while in 
others it becomes chronic and gradually extends itself, healing 
in one place and breaking down in another, until constriction 
follows. We remember one case of almost complete occlusion, 
due to an extensive ulceration produced by the injection of a 
considerable quantity of pure carbolic acid into the rectum 
through a fistulous tract. The operator in this case promised 
the patient a cure without the knife and said that all that was 
necessary was to inject some medicine into the fistula.* The 
patient came to us six months after the injection had been made 
and said his suffering had been greatly increased by the treat- 
ment he had undergone. On examination we found a tight 
stricture and a complete fistula. We have treated a number of 
strictures of the worst form caused by non-union of the skin 
and mucous membrane following Whitehead's and the so-called 
;i American" operation. 

Constipation and Impaction. — Constipation may be put 
down as a cause of stricture from the fact that it is one of the 
most frequent causes of ulceration, the said ulceration being a 
result of an injury done to the rectum during the passage of 
some hard fecal mass or from a necrotic condition of the tissues 
that have been pressed upon by the fecal mass. 

Foreign Bodies. — A few cases have been reported where a. 
stricture followed an ulceration set up by the presence of some 



150 DISEASES OF THE RECTUM AND ANUS. 

foreign body in the rectum. A variety of foreign bodies have 
been found in the rectum, some due to accident, others placed 
there by insane people, and still others by criminals to prevent 
the rinding of a pocket-knife or saw by the jailer. It has been 
said that one gentleman, who had been to Europe, secreted a 
number of diamonds in the rectum to escape paying the custom- 
house duties. We have treated one case only in which we 
thought that the stricture was traceable to a foreign body ; this 
was in the case of a locksmith who came to us to be treated for 
piles and constipation. He had all the ordinary symptoms of 
stricture with external piles. Chloroform was administered in 
order that a linear proctotomy might be made. On introducing 
the finger through the stricture something very hard was de- 
tected, which was removed with great difficulty. It proved to 
be an angular piece of iron about three-quarters of an inch 
(2 centimetres) long and half an inch (1.27 centimetres) broad, 
which had become firmly imbedded in the tissues and acted as 
a source of irritation from which the ulceration that produced 
the stricture started. When we showed the piece of iron to 
him he was much surprised and said it was a piece that belonged 
inside a lock. He had been in the habit of holding certain 
pieces of a lock in his mouth while he was filing others, and 
on one occasion swallowed this piece, which caused him much 
anxiety for a few days, but as it never gave him any further 
trouble he supposed that it had passed out with the contents of 
the bowel. 

Parturition is mentioned as a cause of stricture. We have 
never seen a case in which we thought the stricture due to this 
cause; we believe that such an occurrence is quite rare. 

Syphilitic. 

Syphilis in the form of gummatous deposits within the 
rectal walls or from ulceration certainly heads the list of causes 
of stricture of the rectum. In fact, we believe it to be the cause 
of as many strictures as all other causes put together in dis- 



BENIGN STRICTURE. 151 

pensary practice. Just what percentage of cases of stricture 
are due to syphilis is a much mooted question and has been the 
cause of much controversy. Allingham endeavors to throw 
some light on this question by recording one hundred cases 
observed by him in private practice and at St. Mark's. He 
says: "On summing up my own statistics I can, in short, state 
that, in women, 42 out of 80 had suffered from, or were suffering 
from, undoubted constitutional syphilis, and, in 20 males, half 
were in the same condition ; thus, out of a total of 100 patients, 
52, or more than one-half, were syphilitic."* He ascribes the 
causes in the other 48 cases to tuberculosis, dysentery, diarrhea, 
constipation, and surgical operations; while in a large number 
he was unable to assign any cause. 

Qrippsf places on record 70 cases of stricture recently ad- 
mitted to St. Bartholomew's Hospital, and gives the probable 
primary causes, as follow : — 

1. Syphilis, . . 13 

2. Childbirth, 8 

3. Operations for piles, 8 

4. Operations for fistula, 2 

5. Congenital, ....... 2 

6. Inflammation of the bowels, 2 

7. Internal fistula, ...... 2 

8. Dysentery, 2 

9. Tubercular diseases, . . . .1 
10. Unassigned, . 30 



Total, ........ TO 



Of the 70 cases, 63 occurred in women and 7 in men. 
It would appear, from the foregoing table, that 18 per cent, 
represents as nearly as possible the proportion of cases of 
stricture which can be fairly assigned to syphilitic origin. 
Cripps would lead us to believe that some authors attribute 
stricture to syphilis without due evidence, and asks why it is 
that this diathesis should so much more frequently lead to 

* Allingham, Diseases of the Rectum and Anus, p. 278. 
t Cripps, Diseases of the Rectum and Anus, p. 226. 



152 DISEASES OF THE RECTUM AND ANUS. 

stricture in women than in men, for a much larger number of 
males than females suffer from syphilis, — about the proportion 
of ten to one, — a proportion exactly reversed in the frequency 
of stricture. He believes that the true explanation of the pre- 
ponderance of this disease in females, whether specific or other- 
wise, is to be sought rather in the anatomical relations of the 
rectum than in any constitutional diathesis. In the last two 
years the author has treated 25 cases of stricture of the rectum 
and assigned them to the following causes : — 

1. Syphilis, 13 

2. Tuberculosis, 2 

3. Diarrhea, * . . .2 

4. D^ysenterv, ....... 1 

5. Rectal catarrh, 2 

6. Traumatism, 2 

7. Unknown, 3 

Total, . . . . . . . .25 

Of the 25 cases, 20 were in women and 5 in men ; 
13, or more than one-half the total number, had syphilis. 
Again, w r e find that women are apt to suffer more from this 
disease than men, and that syphilis is to blame in a very 
large percentage of the cases. We have not included in the 
above report those strictures which are ordinarily described as 
spasmodic strictures, nor have we included the congenital form 
as given by some authors. From the study of our dispensary 
practice we are firmly convinced that a greater proportion of 
the colored race than of white people are afflicted with strict- 
ures. We ascribe this to the fact that a large percentage of 
negroes have syphilis, either acquired or inherited. Chancroids 
are sometimes found about the anal margin, but rarely extend 
high up into the rectum. It is quite the exception to see a 
stricture from this cause, but when it does occur it can be 
located near the anus. The causes of the other cases of strict- 
ure recorded in the above table were due to some of the various 
forms of ulceration described in the previous chapter, except in 



BENIGN STRICTURE. 153 

the few referred to as unknown. The real cause of these is 
still a mystery, yet they were well-marked fibrous bauds. 
Allingham thinks that, if we understood why women suffer 
more frequently from ulceration and stricture than men. we 
would have the solution of the problem and could tell the 
cause of those strictures which are mysteries at the present 
time. 

Tubercular. 

This form of stricture is not common, for the reason that 
tubercular ulceration rarely ever heals ; consequently, constric- 
tion does not take place. It is not impossible for a stricture to 
occur, in cases of tubercular ulceration, as a result of induration 
and inflammatory deposits. Kelsey* has seen this condition 
occur too palpably to be mistaken. Patients suffering from 
tubercular stricture are always in a deplorable condition, and 
have little to hope for. 

Catarrhal. 

Inflammation of any portion of the intestinal tract may 
result in a stricture, no matter whether the attack be acute or 
chronic. Certain changes are produced in the rectal wall as a 
result of inflammatory deposits or of cicatrization following 
ulceration, which is started by the mucous membrane's becom- 
ing irritated from the constant passing of large quantities of 
retained and irritating mucus. 

Dysenteric. 

That dysentery causes stricture cannot be doubted; but we 
believe that it is of exceedingly rare occurrence in this part of 
the United States. At the same time we can readily understand 
how it may be a. more common cause in countries where the 
climate is very warm and dysentery is more prevalent. A 
stricture following dvsenteric ulceration usually involves a con- 
siderable portion of the bowel. Sometimes there are multiple 

* Kelsey. Diseases of the Rectum arid Anns, p. 345. 



154 DISEASES OF THE RECTUM AND ANUS. 

strictures, one stricture being- situated above the other. The 
case referred to in the table was one of the latter class. 

Other Forms of Stricture. 

Tn our classification of the forms of stricture we have not 
mentioned the following-, which other authors include : — 

1. Congenital. 3. Inflammatory. 

2. Muscular Bands. 4. Spasmodic. 

Congenital. — We believe that these strictures (malforma- 
tions) should not be treated under this heading, for they prop- 
erly belong to the chapter on congenital malformations* of the 
rectum and anus, where we have described them in detail. 

Muscular Bands. — The semicircular bands which are dis- 
tributed about the rectal wall in a spiral fashion, and which 
sometimes extend for some distance out into the rectum, have 
been mistaken for and diagnosed as strictures of the rectum, 
because a rectal bougie came in contact with them when intro- 
duced into the rectum. Some charlatans take advantage of this 
anatomical fact and make unsuspecting patients believe they are 
suffering from a stricture, and to cure this they exact a large fee. 
This practice is said to have been quite common at one time. To 
illustrate the extent to which this practice was carried on, Mr. 
Henry Smith* tells the following story. He says : " A certain 
gentleman's wife had received treatment with bougies for sup- 
posed stricture. She informed her husband of what had trans- 
pired. He became infuriated at the liberty taken with his wife, 
and called at the house of the practitioner with a horse-whip in 
his hand, intending to punish him. But," the story goes on to 
say, " instead of applying the whip to the operator, he quietly 
submitted and had the bougie passed upon himself." Such was 
the influence of the surgeon in question in persuading his pa- 
tients to believe that they were suffering from stricture of the 
rectum. 



Henry Smith's Surgery of the Rectum, p. 43. 



BENIGN STRICTURE. 155 

Inflammatory. — We believe with Mathews that inflam- 
mation plays an important part in stricture formation, from 
whatever cause. When ulceration is present, a certain amount 
of inflammation precedes and accompanies it, and is partly re- 
sponsible as a cause of the stricture when it occurs. Sometimes 
a stricture is found independent of any ulceration, as a result 
of the rectal wall's becoming thickened from inflammatory de- 
posits following proctitis. To say that a stricture is of the in- 
flammatory variety is not definite enough, for the same might 
apply to almost any stricture. When there is either an acute 
or chronic inflammation of the bowel, we believe that it should 
be designated as catarrhal, and not inflammatory. Then, any 
one will readily understand just what is meant. 

Spasmodic Stricture. — Probably no other subject concern- 
ing rectal disease has enlisted more discussion than the one now 
under consideration. The bone of contention has been : Is the 
spasmodic contraction of the rectum that is sometimes observed 
a real stricture, or is it a symptom of some other pathological 
condition 1 

Van Buren* says : " Wherever muscular spasm exists, vol- 
untary or otherwise, there must be a cause, reflex or direct, and 
this cause is to be recognized as the disease, and not the narrow- 
ing to which it gives rise. Permanent spasm of involuntary 
muscle I regard as an impossibility." 

Again, f he says : "Neither in imaginary nor in actual 
stricture of the rectum is muscular spasm an element of any 
practical importance." 

LeichtensternJ says: "The existence of such an affection 
no longer calls for serious discussion." 

Mr. Harrison Cripps, § after agreeing with Van Buren and 
other writers that permanent or perpetual spasm of the invol- 
untary muscular fibre is a physiological impossibility, goes on 

* Van Buren, Diseases of the Rectum, p. 260. 
t American Journal of Medical Science, October, 1879. 
\ Lei cli ten stern, Ziemssen's Cyclopedia, vol. vii, p. 484. 
§ Cripps, Diseases of the Rectum and Anus, p. 223. 



156 DISEASES OF THE RECTUM AND ANUS. 

to say that wi There is a condition of temporary, followed by 
permanent, shortening to which muscles, frequently stimulated 
by reflex irritation, are liable." In proof of this statement, he 
cites untreated cases of chronic knee-joint disease. He argues 
that any irritation, as an ulcer, inducing continual reflex con- 
traction in any muscular canal might terminate in a permanent 
shortening of its fibrous elements, thus producing an annular 
stricture, and in these views Mr. Ball, of Dublin, concurs. 
AVhile we have not studied this question sufficiently to give a 
positive opinion as to the correctness of Mr. Cripps's views, we 
must admit that this argument is both ingenious and plausible, 
and the case he reports bears out his assertions. We have 
never seen a case of stricture of the spasmodic variety situated 
above the sphincter muscles, and have heretofore believed that 
such a stricture was a physiological impossibility. We have 
quite often observed a strictured condition within the lower inch 
(2.54 centimetres) of the rectum as a result of reflex spasmodic 
contraction, induced by constipation, fissures, etc., which had 
continued so long that the muscles had become thick, firm, and 
hypertrophied. But it is difficult for us to comprehend how 
such a condition could occur in the rectal wall, above the 
sphincter, unless it is due, as Cripps claims, to the constric- 
tion (shortening) of the levator ani muscles and to the nor- 
mal circular muscular fibres of the bowel. Such cases must 
necessarily be of very rare occurrence. 

Chloroform will settle the question as to whether a stricture 
is sjmsmodic or not. When complete narcosis is obtained the 
stricture, if spasmodic, will at once disappear ; if otherwise, it 
will remain. 

Pathological Anatomy. 

In studying the morbid anatomy of stricture there are many 
points to take into consideration. Not only are the mucous mem- 
brane and the muscular coats of the rectum diseased (it the point 
of constriction, but frequently both above and below. (See 
Plate X.) On post-mortem examination, in most instances, a 




PLATE Xr DIAGRAMMATICAL DRAWING OF STRICTURE OF THE 
RECTUM DUE TO ULCERATION. 



A. Dilafeti Rectum above Stricture.. 

B . Thickened, walls near Constriction . 

C. I'frcmtion at a tut above the Strictnr 






BENIGN STRICTURE. 157 

section of the stricture will have a firm feel, a glistening appear- 
ance like other scar-tissue, will creak when pressed between the 
fingers, and is very hard to cut with the knife. There will be 
found an abundant increase of connective tissue at the seat of 
the stricture and in its immediate vicinity ; all of the rectal 
coats and tissues beneath the same and in the ischio-rectal fossae 
will be found indurated and hard. In cases of long standing, 
ulceration and irregular nodules can be felt both above and 
below the strictured point. Dilatation of the rectum above the 
point of constriction always takes place, — clue largely to fecal 
impaction, — while narrowing is the rule below the stricture. 
Fistula is a frequent complication and acts as a sewer to carry 
off the discharge from the ulcerations. A fistula opens more 
frequently above than below the stricture. Around the anal 
margin and lower part of the rectum will be seen vegetations, 
piles, and tags of skin which are always indicative of a chronic 
discharge. When the fistula becomes stopped up or the sub- 
mucous tissue becomes infected from the poisonous discharges 
an abscess will be the result. This abscess may open into the 
bladder, the vagina, or upon the surface of the body. Fre- 
quently the intestines will be bound together by bands of 
adhesions, the result of a chronic peritonitis. In one fatal case, 
where we succeeded in getting a post-mortem examination, Ave 
found the intestines all matted together and literally covered 

with pus. 

Symptoms. 

The symptoms of rectal stricture must necessarily be both 
local and general. The former are due to ulceration, while the 
latter are caused by mechanical obstruction of the alimentary 
canal ; such an obstruction creates a disturbance in both the 
circulatory and the nervous systems and causes a long train of 
misleading symptoms. The stricture is quite frequently over- 
looked until obstruction takes place. The early symptoms of 
stricture are almost identical with those of ulceration referred to 
in the previous chapter. The earliest symptom usually is that 



158 DISEASES OF THE RECTUM AND ANUS. 

of chronic constipation. For a time these patients get on with- 
out medicine ; but as the constriction narrows down purgatives 
are taken, the stools are softened, and all goes well for a few 
months longer. Then the patient observes that he spends a 
longer time in the closet than of old and that much straining is 
indulged in before the bowel is thoroughly emptied. As time 
goes on this straining increases, and, instead of being constipated 
all the time, he now and then has a diarrhea ; then, for a time, 
diarrhea alternates with constipation. A few days of consti- 
pation will be followed by diarrhea. From this time on, as the 
constriction becomes tighter and tighter, the constipation gives 
way and the diarrhea predominates and the patient is re- 
quired to go to stool many times a day ; in fact, during the 
later stages of the disease these sufferers will spend half their 
time in the closet and will frequently pass small quantities of 
liquid feces. There is a never-ending feeling that the bowel 
has not been thoroughly emptied and that something is yet to 
come away. It is necessary to take the strongest cathartics, 
followed by copious injections of warm water and glycerin, to 
liquefy the feces before they can be voided. The straining and 
tenesmus which accompany the frequent stools are something 
frightful ; in fact, we do not know of any other condition that 
will induce so much suffering. The pain is described as bearing 
down and is probably the result of a large, hard lump of fecal 
matter which rests upon the upper surface of the stricture, but 
cannot be forced through it. The pain during the intervals of 
straining is nominal. In cases of long standing the pain is 
reflected to the neighboring organs, up the back, over the ab- 
domen, and down the limbs. Cramping of the lower extremities 
is not an uncommon symptom of stricture. 

Character of tlie Stools. — Much knowledge can sometimes 
be gained by a close inspection of the stools, yet one must not 
rely too much on the shape of the feces, for they are sometimes 
very deceptive and cannot be relied upon as a positive diagnostic 
sign of stricture, as many of the text-books on general surgery 



BENIGN STRICTURE. 159 

would have us believe. They are never, or rarely ever, normal 
in shape when there is a tight stricture, but are described as 
looking like a pipe-stem, piece of ribbon or tape, and very 
long ; sometimes the motions are flat, again they will be round. 
We have known instances where. the stricture was located high 
up in the rectum, where the motions were large, hard, and 
almost normal in shape ; and many of the older writers would 
have said there was no stricture. This is easily understood 
when we know how readily the soft and semisolid feces can 
pass through the stricture into the lower portion of the rectum ; 
and when there, if not soon discharged, immediate absorption 
of the watery portion takes place, and if a sufficient quantity 
has come down a well-formed motion may be discharged. On 
the other hand, we have many times seen the ribbon-like stools 
when there was not the slightest sign of a stricture, due to the 
spasmodic contraction of the sphincter muscle from fissure or 
ulcer. When a tape or ribbon-like stool is of frequent occur- 
rence it should lead us to suspect a stricture, and a careful 
examination should be made. A short time since my class at 
the University Medical College and myself had the unusual 
opportunity of studying the mechanism of a stricture, so far as 
the stools were concerned, in a woman who was being anesthe- 
tized that the stricture might be divided. The sphincters had 
been thoroughly divulsed, and I was in the act of incising the 
stricture, located one and a half inches (3.8 centimetres) above 
the anus, when the patient commenced to strain and to vomit. 
The stricture was forced down through the external sphincter 
and was presented to the full view of every one. Just then the 
straining increased, and a string of solid feces two feet long was 
forced through it. The string was in diameter the size of an 
ordinary pen-staff; this was followed by a discharge of liquid 
feces, which was thrown out with such force as to lodge against 
the opposite wall, some five feet away, in a manner similar to 
that of water coming out of an ordinary rubber hose the force 
of which is increased by a narrowing of the nozzle. 



160 DISEASES OF THE RECTUM AND ANUS. 

Patients suffering from stricture invariably have a worn-out, 
pinched expression about the face. The tongue will be coated, 
the breath very offensive, and the skin will look sleek and waxy. 
The general appearance of the patient is much like that of one 
suffering from general tuberculosis. 

Peritonitis, either acute or chronic, occurs sooner or later 
in almost every case, and continues until the stricture is cured 
or death ensues from exhaustion. A post-mortem examination 
will always confirm this statement. The inflammation occurs 
as a result of the pelvic peritoneum's becoming diseased, as a 
result of an ulceration started by the pressure of an impacted 
mass in the dilated portion of the colon above the stricture or 
from the absorption of retained poisonous discharges. 

Complications. — As a result of the constant straining and 
venous congestion, irritating discharges, etc., other forms of 
rectal disease — such as hemorrhoids, abscess, fistula, ulcer, 
fissure, and pruritus ani — will be produced, and they cannot 
be satisfactorily cured until the strictured condition has been 
relieved. 

External Appearance of the Anus. — A casual glance at 
the anus of one who has been suffering for a considerable time 
with stricture will be sufficient to convince us that we have to 
deal with a stricture or some other serious rectal disease, as 
cancer or both. The anus will be open, the sphincters loose 
and flabby, and the patients have scarcely any control over the 
feces when once they pass the stricture. Numerous vegetations, 
tags, and flaps of superfluous skin are to be seen on every side, 
or, possibly, an eczema and long, deep cracks, which radiate 
from the anus in every direction and which produce an irritable 
itching. In conclusion, we desire to recapitulate, briefly, some 
of the more common symptoms and complications that might 
be expected in a case of stricture of the rectum. They are : — 

1. Constipation. 

2. Diarrhea intermittent with constipation. 

3. Intense and almost constant straining. 



BENIGN STRICTURE. 161 

4. Feeling as if the bowel never completely emptied itself. 

5. Hectic fever. 

6. Indigestion. 

7. Tympanites. 

8. Loss of sphincteric power. 

9. Discharges of blood, pus, and mucus. (Coffee-ground 
stools.) 

10. Pain reflected to other portions of the body. 

11. Change in size and character of the feces. 

12. Obstruction of the bowel. 

Diagnosis. 

When the stricture is located within two and a half or 
three inches (6.4 or 7.6 centimetres) of the anus, it can be diag- 
nosed easily by simply introducing the index finger upward into 
the rectum until it comes in contact with the constriction. If, 
on the other hand, it is situated higher up in the bowel than 
the finger can reach, it will be very difficult to make a positive 
diagnosis. In these cases the surgeon has an excellent chance 
to test his ingenuity and diagnostic ability. At best the diag- 
nosis must often be uncertain and surrounded with doubt- 
Numerous cases have been reported where persons have been 
treated for stricture of the rectum by well-known and reliable 
surgeons ; yet, a post-mortem examination proved that there 
was none. What the surgeon thought was a stricture was, in 
a few cases, the promontory of the sacrum, while in others it 
was some one of the semilunar bands or valves of the rectum 
against which the bougies had lodged, giving the impression to 
the hand that they had been arrested by a constriction. On the 
other hand, it has been our experience more than once to have 
a bougie double back upon itself when a real stricture was 
present, misleading us into the belief that it had passed some 
distance up into the bowel. Our own Dr. Gross once said : 
" Stricture of the rectum is more frequently described than ob- 
served." From this we infer that he had reference to the spas- 

ii 



1(52 



DISEASES OF THE RECTUM AND ANUS. 



modic variety ; for many cases of the latter were being reported 
in those days. The safest and most intelligent way to make a 
diagnosis of stricture is by the finger if it can be reached. The 
finger should be passed through it. In this way ulceration both 
above and below can be detected, tumors pressing on the rectum 
located, and the exact amount of the bowel included in the 
constriction measured, and, as a rule, the character of the growth 
determined. In other words, we may ascertain whether it be 
syphilitic, dysenteric, tubercular, or malignant. A description 
of the malignant form will be given by Mr. Allingham in 




Fig. 51.— Bodenliainer s Rectal Explore 1 



another chapter. When the stricture is so high that it cannot 
be felt by the finger, we have to resort to the use of some one 
of the many kinds of rectal bougies, the introduction of the 
hand into the bowel, bimanual and vaginal examination, or 
exploratory laparotomy, which is best when there is any doubt 
as to the exact location or character of the disease. For pur- 
poses of examination the conical or olive-shaped tips, fastened to 
a flexible piece of whale-bone (see Fig. 51), are the best bougies 
and are to be had in various sizes. In order that the exact size 
and height of the constricting ring may be determined, bougies 
of different sizes are passed through it until one is found that 



BENIGN STRICTURE. 163 

meets with resistance, then goes through with a jerk, and pro- 
duces the same sensation when withdrawn. This gives the size, 
and, if an elastic band is put around the bougie at the anus 
when the point of resistance is met, it gives the distance of the 
stricture above the anus. In case the passage of the olive- 
tipped bougie should be arrested by folds of the mucous mem- 
brane, the operator should substitute a soft-rubber one with an 
opening tli rough its entire length and inject warm water through 
it ; the membrane w r ill then unfold and the instrument can be 
passed farther up the bowel. Sometimes this procedure needs to 
be repeated. At the same time that the bougies are being 
used, bimanual examination should be made to see if the dis- 
ease can be located. Much information in some cases can be 
gained as a result of a vaginal examination. As a last resort, 
we are justified in introducing the entire hand into the rectum 
for the purpose of diagnosticating a stricture high up. It must 
be borne in mind, as mentioned in another chapter, that this 
method of examination is fraught with much danger. In en- 
deavoring to ferret out the trouble it must be remembered that 
certain enlargements of the prostate, of the uterus, and some- 
times tumors in and about the rectum produce symptoms not 
unlike those present when a real stricture exists. The differ- 
ential diagnosis of benign and malignant stricture is of the 
utmost importance, for the treatment of the two differs very 
much. We cannot do better than to give the following table 
from Ball,* which illustrates the more important points of 
difference : — 

DIFFERENTIAL DIAGNOSIS. 



Non-malignant Stricture. 

1. Generally a disease of adult life. 

2. Essential^ chronic and not im- 

plicating the system for a 
lono- time. 



Malignant Stricture. 

1. Generally a disease of old age. 

2. Progress comparatively rapid 

and general cachexia soon 
produced. 



* The Rectum and Anus, p. 169. 



lte 



DISEASES OF THE KECTUM AND ANUS. 



DIFFERENTIAL DIAGNOSIS (continued). 



Non-malignant Stricture. 

3. The orifice of the stricture feels 

:is a hard ridge in the tissues 
of the bowel. Polypoid 
growths, if present, are felt 
to be attached to the mucous 
membrane. 

4. Ulceration of the mucous mem- 

brane ma}' be present, but 
without any great induration 
of the edaes. 



5. The entire circumference of the 

bowel is constricted unless 
the stricture is valvular. 

6. Pain, throughout the whole 

course, in direct proportion 
to the fecal obstruction, and 
only complained of during 
the effort of defecation. 

7. Glands not involved. 



Malignant Stricture. 

3. Masses of new growth are to be 

felt either as flat plates be- 
tween the mucous membrane 
and the muscular tunic, or as 
distinct tumors encroaching 
on the lumen of the bowel. 

4. Ulceration, when present, is 

evidently the result of the 
breaking down of the neo- 
plasm, and the edges are 
much thickened and infil- 
trated. 

5. Generally, one portion of the 

circumference is more obvi- 
ously involved. 

6. In the advanced stages pain is 

frequently referred to the 
sensory distribution of some 
of the branches of the sacral 
plexus, due to direct implica- 
tion of their trunks. 
*l. The sacral lymphatic glands can 
sometimes be felt through 
the rectum to be enlarged 
and hard. 



Prognosis. 
The prognosis of stricture is invariably unfavorable, so far 
as a cure is concerned, unless it be a very slight one, situated 
near the anus, and uncomplicated by constitutional disturbances. 
Such a case is rarely seen by the surgeon, for the reason that it 
lias not created sufficient pain and annoyance to cause the 
patient to think lie has need of a physician. The history of a 
case of stricture is that the patient is getting worse and worse, 
changing from one doctor to another, never satisfied with the 
treatment he is getting, believing that the physician is after 
" filthy lucre" and not a cure. Thus, on and on lie goes until 
he becomes the most miserable creature in the world and death 



BENIGN STRICTURE. 165 

finally relieves him. We cannot be too cautions in the prog- 
nosis of cases of stricture, and we should inform patients thus 
afflicted that they will, in all probability, never be well again ; 
but if they are willing to place themselves in our hands and 
will follow out all instructions for weeks or months to come, 
we can certainly prolong their lives and make them comfortable 
while they live. A patient who is misled into the belief that he 
is going to be cured, and who submits to a course of treatment 
and pays a good fee, and then does not obtain relief, will never 
forgive the one who has thus deceived him, and the physician 
who did the wrong is lucky if he get off without a suit for 
damages. 

Treatment. 

The treatment of benign stricture of the rectum should 
come under two distinct headings : 

1. Palliative. 2. Operative. 

The main indications in the treatment are to reduce chronic 
induration and ulceration, and to enlarge the constricted part 
of the bowel to such an extent that the sufferer may discharge 
the feces without pain or straining. 

PALLIATIVE. 

Palliative treatment may be subdivided into (a) means 
adopted to liquefy the feces, (b) means that lessen the constric- 
tion by absorption, and (c) means that alleviate pain and build 
up the system in general. 

(a) Under this head comes diet, which always plays an 
important part in the treatment of strictures. The food should 
be of the most simple character, and such as will leave as little 
residue as possible. Milk stands first, and should constitute the 
major portion of the food ; next comes rich, nourishing soups, 
soft-boiled eggs, and a small amount of rare beefsteak. All 
foods known to produce colic or flatulence should be discarded. 
Next to diet come laxatives, which are of great value, because 
they liquefy the feces and allow them to be discharged through 



1G6 DISEASES OF THE RECTUM AND ANUS. 

the stricture, — a thing impossible when they are of a solid con- 
sistence. For this purpose laxative mineral waters in large 
quantities daily are admirable. Next come mild cathartics, 
sulphur, castor-oil, etc. Strong purgatives are contra-indicated, 
though they are frequently prescribed by physicians who are 
not aware of the real condition of the patient. Copious injec- 
tions of warm water and glycerin, however, give the quickest 
and most satisfactory relief to the sufferer. 

(b) Mercury and iodide of potassium in increasing doses 
are usually resorted to in the treatment of strictures which are 
due to syphilitic deposits and other tumors where absorption is 
expected to follow medication. Medication will not be of any 
service where the stricture has been long in forming. Stricture 
caused by scar-tissue, the result of ulceration from whatever 
cause, is unchangeable so far as absorption is concerned. Cases 
where it is possible to cause absorption are materially benefited 
by gentle massage of the stricture with the finger, or by a 
suitable rectal bougie. This method will occupy our attention 
under operative treatment. 

(c) Pain and tenesmus in cases of stricture at times become 
so great that something must be done ; in fact, patients who 
have stricture are in constant pain and are extremely nervous. 
To quiet them, opium, morphine, bromides, chloral, and other 
hypnotics and anodynes have to be resorted to; but great care 
must be exercised or the patients will form habits of taking 
these drugs, and they seldom have will-power enough to resist 
these habits when once established. It is preferable, when pos- 
sible, to relieve them by the local application of hot salt, flannels 
wrung out of hot water, or hot poultices over the anns, abdomen, 
and pelvis. Massage of the abdomen by gentle hands helps to 
break np fecal accumulations, which can then be discharged, 
and relieves flatulency to a marked degree. We must look 
after the patients' general health and prescribe tonics, such as 
codliver-oil, preparations of iron and malt when indicated, and 
their taking plenty of out-door exercise should be insisted upon. 



BENIGN STRICTURE. 167 

OPERATIVE. 

As a rule, palliative treatment will prove a failure in so far 
as any permanent benefit derived is concerned ; yet much relief 
can be given by such treatment conscientiously carried out. 
The usual history of a stricture is that it goes on from bad to 
worse, in spite of palliative treatment, until obstruction takes 
place and some surgical procedure is resorted to for relief. 
None of the surgical operations yet devised will give absolute 
relief in all cases of stricture ; yet the relief after some opera- 
tions is very marked. All pain, tenesmus, diarrhea, and strain- 
ing are done away with, and patients rapidly regain their former 
health. The following are the favorite operations for the relief 
of stricture at this date : — 

1. Dilatation : 3. Internal incision. 

(a) gradual ; (b) forcible. 4. Posterior proctotomy. 

2. Electrolysis. 5. Excision. 

6. Colotomy. 

Dilatation.— The operation of dilatation, in some form or 
other, is more frequently resorted to than any other surgical 
procedure because it does not require the use of a knife. By 
the proper use of bougies, many cases of marked stricture with 
accompanying ulceration can be relieved and not a few cured. 
There has been a great difference of opinion as to which is the 
better method, (a) gradual or (b) forcible dilatation; some claim 
that the former is preferable, others that the latter is. So far as 
our own view is concerned, we believe that both are indicated 
in a given number of cases. We believe that gradual dilatation 
has become of greater usefulness than the forcible for the reason 
that it can be applied to any portion of the rectum. It is not 
safe to dilate the rectum forcibly when the stricture is more 
than two and a half inches (6.4 centimetres) above the anus, on 
account of the danger of rupturing the bowel and the setting- 
up of a fatal peritonitis. . When gradual dilatation is practiced, 
it is better to use a bougie that will pass the constriction with 
ease than one that will catch and require force, for the reason 



168 



DISEASES OF THE RECTUM AND ANUS. 



that gentle friction seems to hasten absorption much in the same 
way as massage does in other tumors. When force is used 
inflammation and irritation may be set up that will do more 
harm than if the bougie had not been passed at all. There is 
nothing more tempting than to force a bougie through a strict- 
ure in which it has lodged. All patients treated by gradual 
dilatation should be warned that it will, at least, require a 
number of iveelcs or months to effect any permanent benefit, 
else they will think they are being treated for their fee only and 
go to some other surgeon. It is not at all necessary that the 




Fig. 52.— Correct Method of Introducing a Rectal Bougie. 



surgeon should do all the work, especially when the constric- 
tion is in the lower part of the rectum, for the patient can be 
taught how to use the bougies himself. The short ones are 
preferable. (See Fig. 52.) They should be passed daily and 
left in from five to ten minutes, and the patient should be 
instructed to return to the office once a week to see what 
progress has been made. Gradual dilatation is not indicated 
when the constriction is within the lower two inches (5 centi- 
metres) of the rectum, for the reason that it takes too much 
time to do any good, while with forcible dilatation we can 
accomplish the same in five minutes and save the patient much 



BENIGN STRICTURE. 



169 



annoyance and expense. It can be accomplished, in a variety 
of ways, with a Sargent, Durham, Whitehead, or other kind 
of mechanical rectal dilator (see Figs. 53 and 54), a Pratt 




Fig. 53.— Whitehead's Dilator. 



speculum, or with the fingers. Soft-rubber bougies or fingers 
are preferable to other means of dilatation from the fact that 
much damage to the rectum is likely to be done when any of 
the various mechanical dilators are used. 




Fig. 54.— Durham's Dilator. 



Bougies. — There are many forms of bougies. (See Figs. 
bb and 56.) Ordinarily we prefer those about twelve inches 
(3^- decimetres) long and made of red rubber (Wales). They 
have an opening through the centre through which the bowel 




Fig. 55. — Set of " Aloes" Hard-Rubber Bougies. 



can be irrigated with medicated solutions. They can be had in 
any size. (See Fig. 56.). Allingham used hollow, vulcanited 
tubes of different sizes with a shield to prevent them from slip- 
ping into the bowel. (See Fig. 78.) For the purpose of dila- 



170 



DISEASES OF THE RECTUM AND ANUS. 



tating the stricture, Mr. Cripps* has made twelve sizes with a 
slight uniform taper from base to apex, while their length prob- 
ably increases from four and a half inches (11.4 centimetres) in 
No. 1 to five and a half inches (13.9 centimetres) in No. 12. 
The diameter at the base increases from one-fourth of an inch 
(6.3 millimetres) to one and three-eighths inches (3.5 centi- 
metres). It is rarely necessary to have the bougie retained for 
more than a few moments. If it is desired to keep the bougie 




Fig. 5G.— Wales's Soft-Rubber Rectal Bougies. 



in for some time, it can be attached to and held in place by 
means of a T-bandage. Sponge and laminaria tents, inserted 
within the stricture and left there, will gradually dilate the 
constriction and will prove serviceable in some cases. 

Electrolysis. — Personally, we have not bad any experience 
with this method of treatment; but, from observations we have 
made of its use in causing absorption in growths and tumors 
in other portions of the body, we believe that very little good 

* Cripps, Diseases of the Rectum and Anus, p 214. 



BENIGN STRICTURE. 171 

can be accomplished by it. We think that nearly, if not all, 
surgeons will concur in this belief, notwithstanding the fact 
that text-books on electricity claim that many cures have been 
effected by the proper use of electricity. It is used by means 
of various-sized electrodes' being passed within the rectum and 
the currents' being turned on ; the strength of the current to be 
regulated to suit the case. For further information on this 
method of treating stricture, we respectfully refer the reader to 
the standard works on electro-therapeutics. 

Internal Incision. — This consists in passing a probe- 
pointed bistoury into the rectum and incising the stricture in 
one or more places as indicated. When the stricture is annular 
or due to a fibrous band stretching across some portion of the 
bowel within two inches (5 centimetres) of the anus, this 
method will prove sufficient in many cases, if proper attention 
is paid to the after-treatment. The internal division of strict- 
ure is generally condemned because of the frequent occurrence 
of septic disturbances, abscesses, and fistulas following the oper- 
ation, thought to be the result of improper drainage, and also 
to the danger of concealed hemorrhage. Owing to these 
dangers, it should not be performed in cases where a consider- 
able portion of the bowel is constricted and ulcerated. The 
following case was suited to this operation, as the result will 
show : — 

Case XYIII. — Stricture due to a Muscular Band. 

A lady, aged 27 years, who had been suffering from stricture for 
two years, complained of the ordinary symptoms, except ulceration. 
Examination revealed the presence of a narrow, circular band one-fourth 
of an inch (6.3 millimetres) in thickness, about one and a half inches 
(3.8 centimetres) above the anus, extending entirely around the rectum. 
This was divided behind, before, and on both sides, and the rectum 
cleansed. The after-treatment consisted in passing a bougie (full sized) 
twice a week for two months, when she was discharged cured. Several 
months afterward she informed me that she was entirely relieved. 

I have treated a number of other cases uncomplicated by 
extensive ulceration with fair success. When accompanied by 



172 DISEASES OF THE RECTUM AND ANUS. 

ulceration, a hollow tube (see Fig. 77) should be left in to 
insure perfect drainage and to guard against concealed hemor- 
rhage. 

Posterior Proctotomy. — This operation has been revived 
and popularized by Verneuil, of Paris, and is sometimes given 
the name of linear or external proctotomy. This method of 
treating stricture has not as yet been received with much favor 
by surgeons in general, but it is gaining friends every year. 
We now find prominent surgeons, as the Allinghams (Sr. and 
Jr.), Van Buren, Kelsey, and Cripps, advocating it in cases of 
threatened obstruction, accompanied by extensive ulceration, as 
the best operation, barring colotomy. On the other hand, we 
find that Mathews f gives preference to the simple division of 
the stricture at different points. In our own experience we 
have found that posterior proctotomy has many advantages over 
the internal division, and that it is a valuable substitute for 
colotomy in all bad cases of non-malign ant , ulcerating stricture. 

Advantages of Posterior Proctotomy. — 1. It permits of free 
drainage through the deep triangular incision. 2. Any hemor- 
rhage that might occur can be readily detected and arrested. 
3. It allows the free discharge of accumulated feces and imme- 
diately does away with all straining, pain, diarrhea, and 
tenesmus. 4. It admits of free irrigation and medication both 
above and below the stricture. 

It has been our practice to perform this operation after the 
following manner: With the patient in the lithotomy position, 
the limbs well flexed and held in position by means of Clover's 
crutch (see Fig. 68), the anus and surrounding parts are 
cleansed, shaved, and the rectum irrigated. We then select a 
straight, probe-pointed bistoury of good length, which is placed 
flat upon the finger and introduced within the anus and passed 
upward until the constriction is felt ; then the knife is thrust 
through it and made to pass backward to or near the sacrum. 
It is then withdrawn, cutting the stricture and all intervening 

t Mathews, Diseases of the Rectum and Anus. First edition, p. 356. 



BENIGN STRICTURE. 173 

tissues, including the sphincters, downward and outward to a 
point opposite to the coccyx, thus making a long and deep tri- 
angular cut. If on examination it is found that all the con- 
striction has not heen severed, the operation is repeated. 

The rectum is then irrigated with a sublimate solution of 
1 to 5000. the incision packed with dry iodoform gauze, and 
the patient placed in bed. to have one-fourth grain of morphine 
hypodermatically at bed-time if suffering much pain. 

The after-treatment consists in daily flushings of the rectum 
with any good antiseptic or medicated solution. The dressing- 
is completed by the insertion of dry gauze in the wound to pre- 
vent its healing too quickly and to assist drainage. When granu- 
lations become sluggish, the application of silver nitrate or the 
balsam of Peru will prove serviceable. It is necessary to pass 
a good-sized bougie from time to time to prevent too much con- 
traction. The following case will illustrate the ordinary history 
of a stricture treated by posterior proctotomy : — 

Case XIX. — Stricture of the Rectum. 

Male, aged 40 : father of a large family ; history of syphilis : had 
no bad habits except inveterate smoking. Several months previous to 
the time he came under my care he was troubled with constipation, but 
could obtain relief after large doses of castor-oil and Epsom salts. Later, 
the constipation became worse and the fecal discharges mixed with pus. 
blood, and mucus. He had frequent pains in pelvis, up the bach, and 
down the limbs, and his complexion was muddy. He became ill-tempered 
and despondent. The strongest purgatives failed to give relief, except 
when assisted by copious injections of water and glycerin, and when 
the motion did come it was ribbon-like and never of natural formation. 
At this time the constipation began to alternate with diarrhea, and 
nothing could pass the constriction unless it was fluid or semisolid. 
The patient spent a large part of his time in the closet straining, never 
getting any satisfaction, always feeling that the bowel had not been com- 
pletely emptied. He went from one physician to another, each treating 
for chronic diarrhea. He was treated for six months by electricity with- 
out the slightest benefit, the symptoms in the meantime becoming more 
and more exaggerated until immediate obstruction was threatened. 
Then the family physician was called; he made a digital examination 



174 DISEASES OF THE RECTUM AND ANUS. 

and discovered a stricture, two and a half inches (6.4 centimetres) above 
the anus, which was so tight that the smallest-sized rectal bougie could 
not be passed through it. I was then called into make an examination. 
By palpation I found that the sigmoid and the descending colon were 
filled with impacted feces. It was decided to do the operation now under 
discussion and a proctotomy knife was passed through the constriction 
and then backward until its point came into contact with the bony struct- 
ures, downward and outward to the tip of the coccyx, including the 
sphincters. All ulcers, both above and below the stricture, were curetted 
and a silver solution applied. The after-treatment was carried out as 
previously described. Two weeks from the time the operation was per- 
formed the patient left the hospital and came to my office twice a week 
to have the bougie passed. At the end of the sixth week he went on the 
road as a commercial traveler, armed with a No. 12 Wales bougie, 
which he passes from time to time. One year from the time I first saw 
him, he told me that he had practically no further trouble. It is my 
desire to record this case on account of the marked benefit derived from 
the operation. At the same time, it is with regret that I am forced to 
state that in a very large percentage of the cases of stricture treated by 
this or other methods short of colotomy such good results cannot be 
obtained, but that the operation of posterior proctotomy will always 
afford as much immediate relief as any other. 

Excision. — Excision is more frequently practiced as a 
secondary operation after colotomy has been performed for 
malignant stricture than for benign stricture of the rectum. 
We have, in two cases of stricture, removed that portion of the 
rectum involved and brought the remaining portion down and 
stitched it to the skin. In the first case the result was perfect ; 
but, in the second, union of the skin and mucous membrane 
failed to take place, leaving a circular band of ulceration that 
required months to heal, and, when it did heal, considerable 
constriction followed and the patient was in almost as bad a 
condition as when he came to us for treatment. From this time 
on we shall not attempt the cure of a simple stricture by ex- 
cision, for the reason that, in linear or posterior proctotomy, we 
have an operation that will give just as much relief and the 
danger is less. 

Colotomy. — That colotomy is the best of all operations yet 




CD 

PC 



K CD 

§ LJ 

CD CD 

P-, W 

CD CD 

CD '— ' 

^ CD 

D- g 

CO ,— ' 

PC 

p 

<C CD 

-3 W 



CD c— • 






BENIGN STRICTURE. 175 

devised for the immediate relief of a bad stricture, benign or 
malignant, cannot be denied. It has been our good fortune, in 
a number of instances, to see patients who were almost dead 
from exhaustion, as a result of the incessant diarrhea, tenesmus, 
and pain, restored to comparatively good health and usefulness 
in a short time after a colotomy had been made. After 
colotomy has been performed any impacted feces in the colon, 
sigmoid, and upper part of the rectum can be dissolved and 
brought away by copious injections of water, oil. and Castile 
soap. After this all the feces pass out at the artificial opening, 
leaving the rectum free and clean. Any ulceration present can 
be made to heal by medicated solutions passed through the 
rectum and out at the opening in the groin. The benefit of 
this at once becomes obvious. In case the ulceration and 
stricture are cured the opening in the groin can be closed. The 
surgeon will rarely be called upon to do this, from the fact that 
patients do not wish to take any chances of having to go through 
their former suffering. Most of them wear a truss similar to 
that worn for hernia, and go about their ordinary duties and 
say that the artificial anus causes them very little annoyance. 
The manner of performing colotomy will be discussed by Mr. 
Allingham in another chapter. 

ILLUSTRATIVE CASES. 

Case XX. — Stricture of the Rectum, with Almost Complete 

Obstruction. 

Mrs. A. was referred to me by Dr. B. to be treated for stricture of 
the rectum. She gave the following history : Said she was 30 years old 
and that her family history was good. I could get no positive evidence 
that she had sj^philis, though I suspect that her husband is being treated 
at present for this disease. She first noticed that there was something 
the matter with the rectum two years before I saw her ; at this time she 
had a hemorrhage from the rectum following an attack of constipation. 
After this the constipation became worse; the feces were not of natural 
formation, but always small and nodular or soft and ribbon-like, and 
were expelled with difficulty after much pain and straining. Later the 
constipation gave way to diarrhea, forcing her to spend the major portion 



176 DISEASES OF THE RECTUM AND ANUS. 

of her time in the closet endeavoring to empty the bowel. The liquid 
portion of the feces was readily discharged and the solid portion seemed 
to remain. The contents, when expelled, were streaked with blood or 
pus, and when she left the closet the bowel felt as if it had not been 
completely emptied. In brief, she had all the symptoms that usually 
accompany a stricture of the rectum. 

Examination. — On making a digital examination I detected a 
stricture two and one-half inches (6.4 centimetres) above the anus, the 
edges of which were ulcerated and the whole rectum was saturated with 
a foul discharge. The constriction was so tight that a No. 4 Wales 
bougie would not pass it. I warned her of the danger of obstruction, it 
now being six weeks since she had passed any solid feces, the colon and 
sigmoid being packed with them. Colotomy was advised ; she declined ; 
and instead I performed linear proctotomy, but told her the relief would 
be only temporaiy. For three months she did well, but at the end of 
one year she came back and said she was willing to have the other oper- 
ation performed if it would give her permanent relief from the pain and 
straining. 

Operation. — An incision was made, one and one-half inches (.3.8 
centimetres) long, a little above and two inches (5 centimetres) to the 
inner side of the anterior spine of the ilium ; the peritoneum was opened 
and stitched to the skin. The descending colon was located without 
difficulty and brought outside. The mesentery being long, it was thought 
best to remove a considerable portion of the colon as a preventive to a 
prolapse. Accordingly, the gut was pulled up from below until it was 
taut, and the same way from above. This left about eight inches (2 deci- 
metres) on the outside. A supportive stitch was then passed through 
the mesentery near the gut on one side of the loop, and the same way on 
the other, thus including all the mesentery; it was then pnssed back 
through the skin of the same side and tied. The two portions of the 
gut forming a loop were thus brought in contact. This insured a good 
spur. Several interrupted sutures were taken to fasten the loop of the 
intestine to the abdominal wall. The dressing consisted in covering the 
gut and abdomen with oil-silk smeared over with vaselin, covered with 
iodoform gauze and cotton ; over these a snug bandage was applied and 
the patient put to bed. She came out of the anesthetic nicely in half an 
hour and was suffering very little. I did not see her again until 11 
o'clock at night, — some eight hours after the operation. The nurse 
informed me that she had been vomiting, but otherwise she had been 
very comfortable. I make it a rule in all colotomy cases to remove the 
bandage every time 1 see the patient, to be certain all is well. When I 
did so in this case I found the abdomen covered with coils of the small 



BENIGN STRICTURE. 



177 



intestines — several feet in all — that had slipped out beside the colon, 
where a stitch had given wa} 7 . They were still warm, for the reason that 
the oil-silk had retained the heat. I immediately bathed them with car- 
bolized water, replaced them, and packed the opening with gauze to 
prevent a recurrence of the prolapse. The next morning her pulse and 
temperature were normal and continued so until she was discharged. 
The first two days she suffered some from gas, but received immediate 
relief on the third day, when that portion of the colon outside was re- 
moved. (See Fig. 57.) From this time on her recoveiy was uninter- 
rupted, but was delayed somewhat on account of the retraction of the 
gut. At this time — one year since the operation — she is perfectly com- 
fortable, her bowel acts once a da} T , and the ulceration, which is much 
improved, is being treated by irrigation and local applications both from 
above and below. I report the case to call attention to the importance 




Fig. 57.— Appearance of Gut Before Removal. 

of removing the bandage frequently to see that none of the intestines 
protrude, for there is no doubt in my mind but that I saved this patient's 
life bj T taking this precaution. The accompanying illustrations will show 
the appearauce of the gut before it was excised and of the artificial anus 
at the present time. (See Fig. 58.) The lower opening is almost closed 
and the upper very much reduced in size, due to vicious cicatrization 
that so often follows operations on negroes. 

Case XXI. — Stricture of the Rectum. 

Mr. S. W. came to me suffering from the usual symptoms of stricture 
of the rectum, — diarrhea, straining at stool, reflected pains, etc. Digital 
examination revealed the presence of a well-marked stricture that seemed 
to be of a cicatricial nature, two inches (5 centimetres) above the anus. 
It was so tight that I could not get the end of my index finger through 



178 



DISEASES OF THE RECTUM AND ANUS. 



it ; immediately below the constriction the rectum was nigged and indu- 
rated from ulceration. 

Treatment. — It was thought best te do a posterior proctotomy. The 

patient was anesthetized and placed in the lithotomy position, and the 
rectum irrigated. A probe-pointed bistoury was selected and guided to 
the strictured point by the finger, and then passed up until well above? 
then backward and downward as previously mentioned. This left a deep, 
triangular wound that would readily admit the hand. The incision was 
followed by a gush of blood, which continued to flow freely until the 
ulcerated spots had been curetted and the rectum tightly packed with 
iodoform gauze and cotton and supported b\' a T-bandage. The after- 
treatment consisted in daily irrigations with a bichloride solution, after 




Fig. 58.— Appearance of Artificial Anus One Year After Operation. Opening into Uectum 
Partially Closed as the Result of Vicious Cicatrization. 

which the wound was loosely packed with the gauze. Every other da}' 
a No. 12 Wales bougie was passed to prevent contractions taking 
place to an undesirable degree. From the end of the first week after the 
operation he had no pain and all of the local S3 T mptoms had disappeared. 
At the end of a month he left the hospital, could retain feces, and 
had only one well-formed motion daily. He was warned that if he did 
not pass the bougie regularly another operation would be required. 



Case XXII. — Stricture due to Fibrous Band. 

Miss L., with the usual symptoms, was referred to me \>y a neigh- 
boring physician to be treated for stricture. I detected the constriction 
one and a half inches (3.8 centimetres) up the bowel. The latter seemed 



BENIGN STRICTURE. 179 

normal in other respects. The constriction had not been produced as a 
result of ulceration as in the previous cases, but' was due to a band which 
appeared to be made up of fibrous tissues about half an inch (1.3 centi- 
metres) thick. 

Treatment. — I thought this a suitable case for gradual dilatation, 
for the } r oung lady was in no hurry and preferred this method to a more 
radical one. She was instructed to call at my office every other day. 
On the first day a No. 6 Wales bougie was passed with some little 
difficulty ; at the end of the first week a No. 8 could be passed ; at the 
end of the third week a No. 10 ; by this time she was much relieved and 
was having only one action daity, and that with very little inconvenience. 
Six weeks from the time the treatment was started I could easil}- pass a 
No. 12, the largest size, without causing acute pain. All pain ceased and 
she felt perfectly well. She was discharged with instructions to call at 
the office and have the bougies passed if she noticed any tendenc}- to 
constriction. 



CHAPTER XVI. 

HISTOLOGY, ETIOLOGY, DIFFERENTIAL DIAGNOSIS, AND 
PROGNOSIS OF HEMORRHOIDS. 

We believe, with Bodenhamer, that there is no disease 
within the whole range of medical literature which has a more 
ancient history, which claims a hoarier antiquity, and a more 
conspicuous sacredness than hemorrhoids. Frequent reference 
is made to them in the Bible. The first recorded mention is in 
the first book of Moses, where he threatens his people for dis- 
obedience. The twenty-eighth chapter of Deuteronomy, twenty- 
seventh verse, expresses the following curse : " The Lord will 
smite thee with the botch of Egypt and with the emerods." In 
the ninth verse of the fifth chapter of I Samuel we shall find 
that the men of Ashdod, Gath, and Ekron were afflicted with a 
plague : " They had emerods in their secret parts." Psalm 
lxxviii reads : " And he smote his enemies in the hinder parts." 
The term hemorrhoids, as described by the Greeks, literally 
means a flow of blood, and was coined by them to denominate 
a hemorrhage coming from the veins of the rectal portion of 
the large intestine. Galen interpreted the term hemorrhoids to 
mean a passive and not an active hemorrhage. Some authors 
define hemorrhoids as being vascular swellings situated near 
the anal termination of the rectum. Others use the term to 
designate peculiar tumors of the rectum and anus, whether 
accompanied by hemorrhage or not. At the present day all 
agree that the term does not convey a correct idea either of the 
seat, nature, or cause of the disease. Yet, for ages past the 
term hemorrhoids has been understood as pertaining to certain 
diseases about the rectum and anus; hence, the term should 
not be discarded altogether, though it may be scientifically 
inexpressive of the disease under consideration. Before pro- 
ceeding farther we desire to mention the remedy employed to 
(180; 



CLASSIFICATION OF HEMORRHOIDS. 181 

relieve those afflicted with hemorrhoids in Biblical times. It 
seems that the Philistines sought their priests and asked them 
what they must do to obtain relief. They were instructed by 
the priests to prepare five golden images of the emerods (hemor- 
rhoids), " which mar the land," place them in the ark of the 
Lord and return the same as a tresspass offering to the Israelites 
from whom they had taken it. This they did and were accord- 
ingly healed (I Samuel, sixth chapter). It seems that none 
were exempt, old, young, rich, or poor. The same might be 
said of the hemorrhoids at the present day. This malady will 
in all probability be handed down to succeeding generations, if 
they are subject to the same natural laws, for in all ages the 
same causes produce the same effects. 

Among the number of diseases to which we are liable 
there are none more common, few so tedious and annoying or 
more acutely painful, than hemorrhoids, or piles. The disease 
is so prevalent in this country that, until it attains an aggra- 
vated condition, persons do not deem it of sufficient importance 
to consult their medical advisers ; they are content either to use 
the nostrums of some reputed quack or such local applications 
as are recommended by a neighbor who has been relieved. 
Others defer seeking medical aid from the fact that they are 
ashamed to submit to an examination ; and still others do so 
laboring under the belief that the disease is incurable. 

Classification. 

For hundreds of years past hemorrhoids have been broadly 
divided into two varieties : — 

1. External. 2. Internal. 

This classification is based on pathological facts. Piles are 
called external when the skin alone is involved and the tumor 
is external to the external sphincter muscle, while the internal 
commence in and are covered by the mucous membrane. It 
often happens, in long-standing cases, that internal piles protrude 



182 DISEASES OF THE RECTUM AND ANUS. 

outside the anus, yet, when they are returned into the bowel, 
they will remain for a short time, at least; but the external 
cannot be pushed up into the bowel. Should only a portion be 
returned while the other remained on the outside, it might 
properly be termed a combination pile ; but it should be treated 
like the internal variety. It is very important that a correct 
diagnosis be made, for the treatment suitable for the one is 
contra-indicated in the other. The difference in color is well 
marked ; the external has a purple tint and an irregular surface, 
while the internal has a smooth, shining surface, either red or 
claret colored. 

Etiology. 

When we enter into the study of the causation of this 
disease we at once find ourselves confronted with an almost 
unlimited number, which have been mentioned from time to 
time. It at once becomes apparent that neither sex nor station 
in life is a bar against its ravages ; the weak and strong are 
equally subject to it. It then behooves us to search for one 
common cause that is likely to produce the same condition 
under the varying circumstances and conditions of life. The 
prevailing opinion would indicate the cause to be an anatomical 
one. This we are inclined to believe is correct. Yet we are 
free to say that we are not exactly positive as to just what this 
cause is. We are inclined to the belief that there is more than 
one factor entering into it. The erect position man occupies 
may, from gravity alone, be conducive to piles, for, as Van 
Buren very correctly says, " There is no disease among quadru- 
peds which might be likened unto them." It certainly looks 
plausible that the erect posture might, at least, be a factor in 
the production of this common disorder. Again, the rectum is 
abundantly supplied with veins which enter into the formation 
of the hemorrhoidal plexus. A portion of this blood is returned 
tli rough the internal iliac to the inferior cava, the rest by way 
of the inferior mesenteric to the liver; and these veins, like 
others of the portal system, have no valves. The branches of 



DIFFERENTIAL DIAGNOSIS OF HEMORRHOIDS. 183 

the superior hemorrhoidal veins in their journey upward pass 
through little slits in the muscular wall, and therein, Verneuil 
claims, is to be found the cause of this disease. He believes 
that the dilatation is due to the obstruction of the calibre of the 
veins from the muscle's contracting on them as they pass through 
it. While this anatomical fact undoubtedly tends to dilatation 
under certain conditions, it does not seem to us to be sufficient, 
of itself, to account for the enlargement of the veins in all cases. 
We know that the rectal and anal plexuses have no valves, and, 
further, that when a patient afflicted with prolapsed piles is 
requested to strain down, the piles at once become engorged 
with venous blood as a direct result of the pressure of the 
abdominal muscles. It is not at all unreasonable, then, to 
suppose that the pressure from the above muscles on the blood- 
column or the pressure from a pregnant uterus or some patho- 
logical growth might be productive of hemorrhoids by interfer- 
ing with venous circulation. We will now mention some of 
the more comm'on causes of this disease — such as morbid 
growths of liver, spleen, uterus, ovaries, and prostate — which 
cause venous obstruction. Again, we have other causes — as 
constipation, stone in the bladder, urethral obstruction, and 
purgatives — which are conducive to piles from the intense 
straining which they induce. Congestion of the liver, obstruct- 
ive diseases of the heart, improper diet, and irregular habits, as 
well as inherited predisposition, may all be said to be productive 
ol this very common and annoying disease. Nearly all railway 
employes have this disease, as a result of irregularities in living 
combined with the irregular jarring motion of the train.* 

Differential Diagnosis. 

Hemorrhoids have at different times been mistaken for a 
number of other rectal disorders. The following are the diseases 
which resemble hemorrhoids most : — 

* See chapter on " Railroading as an Etiological Factor in Rectal Diseases." 



184 DISEASES OF THE RECTUM AND ANUS. 

1. Polypi. 4. Venereal warts. 

2. Villous tumors. 5. Frolapsus. 

3. Malignant growths. 6. Pruritus ani. 

7. Hemorrhages. 

Polypi can be diagnosticated from hemorrhoids by their 
soft, smooth, elastic feel, pyriform shape, and long, slender 
pedicle. 

Villous tumors are known by their broad base, slow 
growth, spongy feel, dark-red color, and frequent hemorrhages. 

Malignant growths in the early stage present a number 
of hard nodules on the side of the rectal wall ; at a later date 
they become larger and break down, after which the diagnosis 
is made without difficulty. 

Venereal warts can be distinguished by their large number 
and circumscribed location. They are soft, pedunculated, fra- 
gile, bifurcated, of a dark-red color, and give off a very disagree- 
able odor. 

Prolapsus involves the entire circumference of the bowel, 
while piles are distinct, localized tumors, situated on the side 
of the bowel. The prolapsed tumor is cone-shaped, with a slit 
in the centre, and has a velvet-like appearance. 

Pruritus ani is frequently called itching piles. There is 
no pathological reason for this, since there is an absence of both 
tumors and hemorrhage, while the itching is caused, in a large 
percentage of cases, from some irritating discharge from the 
rectum, thread-worms, and neuroses or eczema of the skin. 

Hemorrhages of all kinds, coming from the rectum, are 
usually attributed to bleeding piles. In many such cases we 
have demonstrated to the class the entire absence of piles; the 
bleeding is due to ulceration, injury, fissure, etc. 

Prognosis. 
The prognosis will prove unsatisfactory in many cases 
where topical applications are relied on exclusively. On the 
other hand, when piles are properly and radically dealt with, 
the results will be surprisingly gratifying in almost every case. 





PLATE XII- THROMBOTIC HEMORRHOIDS. 



CHAPTER XVII. 

EXTERNAL HEMORRHOIDS. 

These are tumors which appear on the outside and just 
below the anal margin ; they are always covered by integument. 
They are so common that few persons arrive at middle age 
without having suffered from them. Nearly all swellings ap- 
pearing about the anal margin are designated by this term. 
This disease is no respecter of persons ; it attacks alike the 
robust, the weak, the rich, the poor, the old, the young, the 
active, and the inactive. External hemorrhoids are divided into 
two classes : — 

1. Thrombotic. 2. Cutaneous. 

Thrombotic. 

Thrombotic or venous piles consist of elevations of the 
skin near the anal margin, oval in form and of a livid color, or 
slightly tinged with blue (see Plate XII), filled with a hard clot 
of blood inclosed in a sac. The amount of pain depends upon 
the inflammation. When the latter is slight no inconvenience 
will be felt other than a sense of heat and fullness. On the 
other hand, if the veins and surrounding tissues become 
actively inflamed, the pain will be very severe and will con- 
tinue so until the clot is turned out or suppuration takes place. 
These tumors form quickly, and usually present themselves 
during the act of defecation following an attack of consti- 
pation necessitating great straining. They have the appearance 
and feeling similar to that of a bullet beneath the skin, and 
they are usually single, though we have frequently seen two, 
three, and as many as six present at one time. They occur as 
the result of excessive eating, irregular habits, and anything 
that is conducive to constipation. 

(185) 



186 DISEASES OF THE RECTUM AND ANUS. 

SYMPTOMS. 

There is usually a sense of fullness and heat, throbbing 
pain, tight sphincter, with irresistible tendency to strain, and 
sometimes an itching sensation. When inflammation is present 
to any degree, the patient will be uncomfortable in any position 
he may assume. He may also have a slight elevation of tem- 
perature, which makes him restless and entirely unfit for business. 

Cutaneous (Hypertrophied Skin). 

This variety consists of hypertrophied prolongations of the 
skin. Cutaneous piles are frequently a result of the other 
variety, a fold of skin being left after the clot has been out- 
turned or absorbed. They may be single or multiple, but usually 
retain the natural color of the skin, which has become thickened. 
They are much aggravated by improper diet, irregular habits, 
and uncleanliness. 

symptoms. 

Unless they become irritated or inflamed they will cause 
little inconvenience ; and, in fact, some persons go all through 
life with them and suffer very little by taking proper care of 
themselves. When people neglect to take care of themselves, 
the piles frequently become acutely inflamed and cause much 
pain and annoyance until they are removed. In many cases 
we have observed the pain reflected to neighboring organs and 
down the legs to the feet, producing some very interesting reflex 
phenomena that might be mistaken for the disease of a neigh- 
boring organ. 

Treatment of External Hemorrhoids. 
The treatment of external piles is simple and the results 
are favorable. It should be both palliative and operative. 
The latter is always to be preferred unless the patient refuses to 
submit to a trivial operation. In such a case much relief is 
to be had from the use of certain palliative measures presently 
to be discussed. 



EXTERNAL HEMORRHOIDS. 187 

Palliative. — In all cases the attention should be paid to the 
diet and errors corrected in the same. Highly-seasoned food 
and stimulants, such as tobacco, whisky, wines, and beer 
should be discouraged, and a simple diet substituted. The 
bowels should be kept open by the use of Vichy, Hunyadi, 
Freidrichshall, or some other reputable mineral water. If there 
are symptoms of a congested liver, a few calomel parvules. one- 
tenth of a grain, or the blue pill properly administered will 
prove beneficial. Frequent hot baths should be taken, and the 
anus washed with Castile soap and water. If the pile belong 
to the first variety, containing a hard clot, frequent applications 
of an ointment composed of 

R Morphinee sulphatis, .... gr. iij ( 0.195 gramme ) ; 
Hydrargyii cliloridi mite, . . . gr. xij ( 0.78 gramme ) ; 
Vaselini, ^j (31.00 grammes) ; 

will soothe the parts and reduce the inflammation. The old- 
time lead-and-opium wash, either hot or cold, applied constantly, 
will afford great relief. We use it in the following proportions : — 

R Liquoris plumb i subacetatis, .... £iv ( 15 c.cm.) ; 

Tincturse opii, 3iiss ( 10 c.cm.); 

Aquae dest., . . . . % . q. s. ad ^iv (120 c.cm.). — M. 

The lead solution mixed with the sugar of milk forms a 
very soothing application. Hot poultices of any kind, if applied 
constantly, will prove valuable in relieving pain and reducing 
inflammation when present in either variety of external piles. 

Operative. — In the thrombotic variety the tumors should 
each be incised, the clot turned out, and some escharotic applied 
to the inside of the pile to insure the closing of any rent in the 
vein. The patient should then be placed in -bed to remain there 
for several hours to prevent the tumors' filling up again. We 
use a sharp-pointed bistoury to make the incision, and often 
apply the Paquelin cautery to the rent in the vessel. This treat- 
ment has always proved satisfactory in our hands. The incision 
should be kept open by the insertion of a small pledget of cotton. 
The surgical treatment of the cutaneous variety differs some- 



188 DISEASES OF THE RECTUM AND ANUS. 

what from the one just referred to, in that the tumor is seized 
with a pair of catch-tooth forceps and then snipped off with a 
pair of curved scissors, care being exercised not to remove any 
more of the skin than is absolutely necessary, lest too much 
contraction follow the operation. When there is considerable 
space left between the edge of the skin and the mucous mem- 
brane, it is best to unite them by catgut sutures. If the sphinc- 
ter has been previously thoroughly divulsed, little pain will 
follow the operation. When there is only one tumor and that 
small, it can be removed with comparatively little pain after an 
injection into it of a 6-per-cent. solution of cocaine. It does 
not make any difference to us, from an operative point, whether 
the pile is inflamed or not, for we always operate on all piles 
just as soon as we obtain the patient's consent. We do not 
believe in palliative measures except when we are not allowed 
to operate. Cases of stricture from operations for external 
hemorrhoids have been reported, but we have never had but 
one follow an operation that we are aware of. We beg once 
more to caution the reader not to remove the entire tumors 
when swollen. When a large raw surface is left after the 
removal of swollen tumors* the pain will be severe, healing 
may be delayed, and possibly stricture may follow. 

ILLUSTRATIVE CASES. 

Case XXIII. — External Hemorrhoids (Thrombotic Variety). 
A gentleman called at my office early one morning and asked me 
to call to see Dr. J., who was suffering from an attack of piles. I re- 
sponded prompt^, and found the doctor in bed, groaning and rolling 
from one side of the bed to the other. On inquiring what was the matter, 
he said his piles were down and strangulated. I requested him to get 
into the Sims position and proceeded with the examination, which 
revealed the presence of two thrombotic piles closely hugging the anus 
at the mnco-cutaneous junction. They w r ere round, hard, dark-blue in 
color, and felt and looked like two bullets beneath the skin, around which 
the sphincter was tightly contracted. I informed him that the quickest 
way to got relief was to have them transfixed with a knife and the clot 
turned out. He said he was willing to do anything to get relief. A 



EXTERNAL HEMORRHOIDS. 189 

solution of cocaine (6 per cent.) was applied to the tumors for five 
minutes to deaden the pain ; then, with a sharp-pointed, curved bistoury, 
I slit each in turn and scraped the clot out witb a sintdl curette, causing 
him very little pain. The relief was so great that he dozed off to sleep 
within fifteen minutes after the operation was completed. The edges of 
the incision were kept apart by a piece of gauze inserted into the pile to 
act as drainage and to prevent its refilling. The next morning he was 
able to make his calls w r ith comfort, and never had a relapse. 

Case XXIV. — External Hemorrhoids (Thrombotic Variety). 

Dr. S. called at m} T office to be examined for rectal disease. He 
complained of very considerable pain, spasm of the sphincter, and sen- 
sations of heat and fullness about the anal margin. He first noticed that 
there was something wrong immediately after he had an action, some 
hours before. Examination revealed a large, hard, bluish-looking tumor 
at the anal margin. A diagnosis of thrombotic pile was made, the tumor 
incised and the clot turned out. I suggested that it would be best for 
him to rest quietly in bed for the remainder of the day, but he replied 
that urgent business demanded his attention and he would be unable to 
do so. The next morning I was not much surprised when the doctor 
walked into the office and remarked that the pile had refilled and was as 
painful as before. He was again placed on the table and the pile incised 
as before, and a small pledget of cotton left in the incision. He imrne- 
diateh' returned to his residence, where he remained quiet for several 
hours, when he resumed his usual duties and had no further trouble. 

Case XXV. — Hemorrhoids (Cutaneous Variety). 

I was called in consultation to see Mr. W. C, who was suffering 
from piles and gave the following history : Age 42; fireman; had always 
been perfectly health}^ until his present illness, except that he was bad^- 
constipated and always had to take a cathartic to move his bowels. He 
was irregular in his habits and drank quite freely of alcoholic stimulants. 
He first noticed that he had piles a week before he came to me. He com- 
plained of pain, heat, and swelling about the anus, and said that for two 
nights he had been unable to sleep on account of the anus's jerking. He 
was extremeh' nervous and his face was pinched in evidence of his suf- 
fering. The pain was of a drawing, burning character. I placed him on 
a lounge in a good light, and, on separating the buttocks, two veiy large, 
external, cutaneous piles presented themselves. They were very sensitive, 
red, and acutely inflamed. He was informed that an operation was the 
quickest and most satisfactory way to get rid of them. He objected to 
having it done, and said that time was no object. The first thing I did 



190 DISEASES OF THE RECTUM AND ANUS. 

was to order a saline cathartic to be given every morning to insure a free 
action. Hot flaxseed-poultices moistened with laudanum were applied 
to the tumors, with instructions for them to be made fresh every half- 
hour, for a cold poultice does more harm than good. Within an hour he 
was fairly comfortable. During the night he awoke a number of times 
when the sphincters would contract, but soon went to sleep again. On 
the following morning the tumors were less sensitive and very much 
reduced in size, and he wanted to sit up. He was requested to remain 
quiet in bed, and the poultices were continued for twenty -four hours, when 
they were discarded and the ice-bag substituted. On the fourth da}' from 
the time treatment was instituted the tumors had all shriveled up and 
were nothing more than l^pertrophied folds of skin, which could be 
handled without causing any pain, and he resumed his daily avocation. 

Case XXYI. — External Hemorrhoids Complicated with Fissure. 

A friend of mine called at the office and asked me to drive out with 
him to see his wife, who was suffering from some rectal trouble. When 
we entered the room she was lying on the bed, apparently perfectl}* com- 
fortable, when she proceeded to give me a history of her case. She was 
32 years old, of a nervous temperament; none of her famify had ever 
died of tuberculosis, and her health had always been good, barring 
habitual constipation, which sometimes caused her to feel dizzy and have 
sick-headache. She had never suffered from any rectal trouble until her 
present attack, which she dated back to the previous week. At this 
time her bowels moved and the feces were large, hard, and nodular, and 
much straining was indulged in before she was able to discharge them. 
When she did, she felt a sharp, shooting pain, which remained several 
hours in the region of the coccyx. Ever since then there had been sen- 
sations of heat and fullness about the .rectum, with now and then sharp, 
drawing, jerking pains. During the last two days she could feel lumps 
at the side of the anus which were exceedingly painful when touched, 
and caused her much pain unless the limbs were flexed and a pillow kept 
between them. On making an examination I found several cutaneous 
tags, one of them swollen, red, and very sensitive. On separating the 
anal margins I discovered an irritable fissure almost concealed within a 
fold of the inflamed pile. I at once advised excision of the tumors ; she 
gave her consent, and I telephoned m}^ assistant to bring my instruments 
and ether spray. Tie came promptly, and the spray was made to play 
upon all the tumors until local anesthesia was produced. Each tumor, 
in turn, was seized with catch-forceps, drawn down, and cut off with 
curved scissors; the sphincters were then gradually dilated with bougies 
and that portion of the fissure remaining within the anus touched with 
the nitrate of silver. In one week the patient was perfectly well. 




PLATE XIII: SHOWING THE PATHOLOGY OF INTERNAL HEMORRHOIDS 

,\ Superior Hemorrhoidal Vfhl.t. 

I! Mo/,//,- 

( Inferior 

I) Hem ori-luiit tal Hexua by removal <il the Mucous Membrane 

I Prtttrmlimj Internal Hemorrhoiils eoveretJ by the Mucous Membrane 



CHAPTER XVIII. 

INTERNAL HEMORRHOIDS. 

Internal hemorrhoids are developed, in many respects, 
like the external variety, and the causes which produce the one 
may also produce the other. Their appearances are similar in 
many respects, hut differ somewhat in color. The internal 
hemorrhoid is covered hy the mucous membrane, and lias a 
bright-red color, while the external is covered by integument. 
Internal piles are more serious than the others, from frequent 
hemorrhage. In old-standing cases they remain outside the 
anus nearly all the time and frequently become ulcerated, which 
causes the patient much pain and annoyance. It is not an 
uncommon thing to see both external and internal piles present 
at the same time, thus necessitating a combination operation to 
insure a good result. The internal variety is due to certain 
changes which take place in the blood-vessels in and beneath 
the mucous membrane. 

Symptoms. 

Some persons have internal piles for years and suffer little 
annoyance from them, while others suffer greatly from the first. 
We have frequently seen strong men and women become emaci- 
ated and nervous from an apparently simple cause, — so much so 
that they were totally unable to attend to their ordinary duties. 
We doubt if there is any other disease which causes more 
mental or reflex disturbances than the one under consideration. 
The most prominent symptom of this variety of piles is the 
bleeding, and from this fact they are frequently denominated 
"bleeding piles." The bleeding is usually preceded by the pro- 
trusion of the tumors during the act of defecation, and may be 
slight or profuse. Sometimes these sufferers bleed until they 
faint and fall over in the closet. When the piles are not 
inflamed, the only inconvenience will be a sensation of heat and 

(191) 



192 DISEASES OF THE RECTUM AND ANUS. 

fullness; but when the tumors become swollen or strangulated 
and the inflammation becomes active, the sphincter will alter- 
nately contract and relax on them, thus producing the most 
excruciating pain, which lasts until they slough oft', have been 
operated on, or are relieved by palliative remedies. In old- 
standing cases the w r alls of the piles become tough and hyper- 
trophied. We believe that the bleeding, in the vast majority 
of cases, is of a venous character, though many high in authority 
differ on this point. 

Cripps* believes the spurting, in cases which appear to be 
arterial, is due to the blood's being forced as a regurgitant 
stream through a rupture in the vein by the powerful abdom- 
inal muscles, and we think he is correct in his theory, yet in 
some instances we have witnessed hemorrhages wherein the blood 
presented every appearance similar to that from an arterial twig. 
In olden times the surgeon was afraid to arrest these hemorrhages 
for fear that some internal disease w 7 ould be developed, such as 
consumption or dropsy. Happily for patients, this superstition 
has almost disappeared. We believe that the bleeding does 
not seriously impair the health of certain plethoric individuals, 
yet the annoyance is so great that, even in such cases, we have 
never failed to see a marked improvement in their general 
health after the bleeding had been arrested ; while in those 
who had become anemic the improvement was very marked 
and rapid. 

Internal hemorrhoids may be divided into two classes, viz. : — 

1. Capillary (Nevoid). 2. Yenous. 

Capillary. — The capillary tumors are smaller than the 
venous, spongy in texture, are formed by the superficial vessels 
of the mucous membrane, and resemble strawberries. They 
may appear alone or be present with the venous variety. They 
rarely protrude and scarcely ever give pain, but always bleed 
profusely. 

* Diseases of the Rectum and Anus, p. 70. 










,-•■ 



1 




PLATE XIV- PROTRUDED HEMORRHOIDS WITH PROLAPSED 
MUCOUS MEMBRANE. 



iurkSMTetndgeCaLithPhila 



INTERNAL HEMORRHOIDS. 



193 



Venous. — This variety is of more frequent occurrence than 
the capillary ; the tumors are large and vary in size from one- 
half to one inch (1.3 to 2.54 centimetres) across their bases, are 




Fig. 59. — Showing Attachment of Internal Hemorrhoids. 



covered by mucous membrane, have a glistening appearance, 
are of a bluish or livid color, and are formed as a result of a 
dilatation of the veins in the submucous tissue. (See Plates 
XIII and XIV.) 



13 



CHAPTER XIX. 

TREATMENT OF INTERNAL HEMORRHOIDS. 

Their treatment will be considered under two headings, 

viz.: — 

1. Palliative. 2. Surgical. 

Palliative. 
By certain palliative measures we have rendered many 
patients comfortable and, in a few cases, reduced the piles 
altogether. When the piles are small and cause but little 
suffering the treatment is simple. In the first place, errors 
in diet and habits of living should be corrected. We have 




Fig. 60. — Hemorrhoidal Truss. 

often seen an acute attack of piles brought on by a prolonged 
spree. When the piles are protruded and inflamed the patient 
should take the recumbent position and keep perfectly quiet, 
and soothing or astringent lotions and ointments should be 
applied constantly. When these fail relief can often be had 
from poultices made of flaxseed, corn-meal, and onions. The 
symptoms of a congested liver should be counteracted at once. 
When the tumors are not large and are not strangulated they 
can be made to contract by the application of pure nitric acid to 
their bases. In fact, in a few instances we have witnessed some 
(194) 



TREATMENT OF INTERNAL HEMORRHOIDS. 195 

happy result from this treatment. If the patient must work he 
can get much comfort from a pile-supporter. (See Fig. 60.) 
The bowels should be kept in a relaxed condition at all times 
and the patient instructed to cultivate regular habits as to the 
time of going to the closet, etc. When the treatment just out- 
lined fails to relieve suffering, the sooner radical treatment is 
resorted to the quicker the patient will be well. 

In the palliative treatment of hemorrhoids there are two 
essential features : the first is to reduce the inflammation as 




Fig. 61.— Appearance of Cross-Section of Internal Hemorrhoids. 

quickly as possible, and the second is to reduce all protruded 
tumors at the very first opportunity. 

Surgical. 

In many cases the surgeon will not be consulted until the 
patient has an acute attack of piles, and then he will not be 
permitted to resort to operative procedures until all palliative 
measures have failed to give relief. We know that such 
measures do at times afford much relief, and, in a few cases, a 
cure. But a much longer time is required and the suffering is 
much greater than if an operation had been performed in the 
beginning. This being the case, and there being no other 



19() DISEASES OF THE RECTUM AND ANUS. 

complications, we advise them to undergo the trivial operation 
necessary for a complete cure at once, regardless of any inflam- 
mation of the piles. The aid of surgery — sought in all ages for 
the cure of piles — has brought much benefit to this class of 
sufferers. Many of the operations now in vogue were practiced 
by the ancients, — such as ligation, cauterization, crushing, etc., 
— with more or less success, but with much pain, for in those 
days anesthetics were not in use. When you have decided that 
an operation is necessary, select the one best suited to the case 
under consideration. We are free to say that we have no one 
operation that we adhere to, but always try to select the one 
best suited for the case under advisement. In turn we shall 
describe each of those most favored at the present day, but shall 
go into the details of such only as have recommended themselves 
to us as being suitable in a large number of cases. 

PREPARATION OF THE PATIENT FOR OPERATION. 

The general health of the patient should be looked into, 
and, if found to be below par, it should be corrected as much as 
possible. The urine should be carefully examined to detect the 
presence of any kidney complication. If the patient have 
malaria a few doses of quinine will prove beneficial; and any 
condition that wotdd tend to produce a relaxation or dilatation 
of the blood-vessels should be remedied as well. On the morn- 
ing preceding the operation two teaspoonfuls of compound 
licorice-powder is given to open up the bowels. One hour 
previous to the same the surrounding parts are cleansed, shaved 
if necessary, and the rectum thoroughly washed out with an 
injection of warm water and Castile soap. It is hardly worth 
mentioning that the patient has not been allowed to eat any 
food for several hours previous to this time. The following 
operations have been recommended by different writers from 
time to time, some of which have not met with much favor by 
American surgeons : — 

1. Application of chemical caustics. 



TREATMENT OF INTERNAL HEMORRHOIDS. 197 

2. By the ecraseur. 

3. Crushing. 

4. Dilatation. 

5. Cauterization (1) by puncture, (2) linear, (3) by gal- 
vano-cautery wire. 

6. Injection of caustic and astringent solutions. 

7. Whitehead's operation of excision. 

8. Ligature (Bodenhamer's modification). 

9. Ligature. 

10. Clamp and cautery. 

11. Submucous ligation (Rickets). 

APPLICATION OF CHEMICAL CAUSTICS. 

Such applications are not indicated in cases where the 
tumors are large and protruded, but in the small, flat, capillary 
variety. The operation is simple and requires only a few 
moments ; much dexterity is required, however, to prevent the 
sound tissues from being injured by the application. 

Many acids have been recommended for this purpose, but 
nitric acid seems to outrank them all, though chromic and car- 
bolic acids have their respective adherents. We have seen a few 
cases where the hemorrhages were arrested permanently, while 
in others they were arrested for a short period only. We well 
remember one case that came near bleeding to death when the 
slough came off, as a result of acid applied. The neighboring 
parts should be protected by vaselin and all excess of the acid 
neutralized with soda, which may be applied to the exposed 
pile with a brush made of cotton twisted firmly on a tooth-pick 
or on a glass rod. Some prefer caustic paste. 

THE ECRASEUR. 

This instrument is highly recommended by French writers. 
English and American surgeons, with a few exceptions, con- 
demn it, for the reason that with either the wire or chain you 
cannot remove, with any degree of accuracy, the desirable 



198 



DISEASES OF THE RECTUM AND ANUS. 



amount of pile-tissue. Sometimes too little will be removed, 
making the operation a failure ; at another time too much, 
causing constriction to a greater or less degree. Of recent years 
we have not used it, for the reason that we have better and 
simpler ways of curing piles. 




Fig. 62.— Pollock's Pile-Crusher. 
CRUSHING. 

While the operation of crushing piles is not extensively 
performed, especially in this country, it has some points that 
merit consideration. There is little danger from hemorrhage, and 
patients thus operated on require a shorter time for recovery and 
suffer less than from the ligature. The operation was introduced 
by Mr. George Pollock, in 1880; and about 1885 Allingham, Jr., 




Fig. 63. — Herbert Allingham's Pile-Crusher. 

began advocating it, but substituted for the pincher-like crusher 
of Mr. Pollock (see Fig. 62), a screw crusher, which we have 
seen used by him at St. Mark's Hospital with satisfactory re- 
sults. (See Fig. 63.) The operation as performed by Alling- 
ham consists in drawing the pile through the crusher, which is 
then tightened. The projecting portion is removed with the 
scissors, and after twenty-five seconds the crusher is removed. 



TREATMENT OF INTERNAL HEMORRHOIDS. 199 

He advises its use when the piles are small and few in number 
only. The operation is not likely to become popular in this 
country, for many of our surgeons would prefer the injection 
method, which is suited only for that class of cases where Mr. 
Allingham uses his crusher. Recently a New York surgeon 
has advocated crushing piles between the thumb and fore- 
finger. It seems to us that this method would only be of service 
when piles are in their incipience/, and would be beneficial for a 
short time only. 

DILATATION. 

Thorough dilatation of the sphincter muscles for the cure 
of internal piles comes highly recommended to us by eminent 
French surgeons, such as Verneuil, Gosselin, Fontan, and many 
others. The operation is performed by inserting the two thumbs 
within the anus and by gentle and constant pressure, gradually 
overpowering the sphincter. (See Fig. 72.) At the same time 
care must be used to avoid tearing the mucous membrane or 
lacerating the muscles. We always use an anesthetic unless the 
patient absolutely refuses to take it. Dilatation can be effected 
by the use of rubber bougies, but the bougies cause more annoy- 
ance, require a longer time, and the results are not so good. 
The operation of dilatation has not proven satisfactory in our 
hands, except in cases where the tumors w 7 ere small and the 
sphincters tight. In such cases, as well as those complicated 
with an irritable ulcer or fissure that induces great suffering, 
we have always relieved patients by this simple procedure. 
Two days after the operation the sphincters are capable of acting, 
but the spasm is gone. The bowel acts freely, and the only 
indication of the operation's having been performed is a slight 
extravasation of blood about the anus. It never detains them 
from work more than three days. 

CAUTERIZATION. 

Cauterization may be used in one of three ways, viz. : — 
1. By puncture (Mr. Reeves). 



200 DISEASES OF THE RECTUM AND ANUS. 

2. Linear. 

3. Galvano-cautery wire. 

Cauterization by puncturing the piles was used by ancient 
surgeons and has been revived from time to time. Mr. Reeves, 
an eminent surgeon of London, has recently endeavored to 
popularize this operation, but lias made a failure of it. Mr. 
Allingham, Sr., tried it in three cases, and says that he made 
a failure in every one. Great pain, retarded recovery, and 
abscesses occurred in two, while the third was not cured. We 
have tried this operation in a number of cases, and our experi- 
ence has been such that we shall not attempt it again, for the 




■^KB 11111 

"~r *********** 



Fig. 64.— Cautery Irons. 

reason that we have recourse to other operations which are 
accompanied by fewer complications and much better results. 

Linear cauterization was introduced in 1875 by Voillemeir. 
He applied the cautery to the mucous membrane within the 
anus, before, behind, to the right and left sides of the bowel, 
and not directly to the piles. The parts, as a rule, were much 
swollen for a few days, during which time water-dressings and 
poultices were applied. The pain is quite severe for about four 
days, and the time for a cure never exceeds one month. The 
benefit derived is from the contraction, which is never enough 
to produce stricture. We have tried this method and found it 
to be very unsatisfactory for ordinary piles, because of the 
amount of pain and delayed healing. We practice linear 
cauterization by applying it directly to every tumor after the 



TREATMENT OF INTERNAL HEMORRHOIDS. 



201 



sphincter has been thoroughly divulsed, which prevents after- 
pain. Our patients are never confined to bed after the second 
day, but are allowed to sit up in a comfortable chair, and at 
the end of the fifth day are discharged with instructions to 
return to the office twice a week, that we may apply some 
stimulating application to any unhealed surface. This opera- 
tion is not suitable in long-standing cases where the tumors are 
large, numerous, and have hypertrophied walls, but will be 
found serviceable in cases where there are no distinct tumors, 
but a general dilatation of the veins on all sides of the bowel, 
with an inclination of the mucous membrane to protrude. 




Fig. 65.— Cautery Blow-Pipe. 

Galvano-Cavtery Wire. — The treatment of piles by this 
procedure has from time to time been revived for a short 
while and then condemned. We have never in our experience 
found a case where we thought we were justified in resorting to 
it. principally on account of the unreliability of the batteries 
and because we can see no advantage that it has over Paquelin's 
or the actual cautery. 



INJECTION OE CAUSTIC OR ASTRINGENT FLUIDS. 

For a number of years the treatment of piles by the injec- 
tion method was confined almost entirely to quacks, who went 
about the country advertising to cure them without the knife or 



202 DISEASES OF THE RECTUM AND ANUS. 

the necessity of the patient's absenting himself from his daily 
vocation. The method is supposed to have been originated by 
a young physician named Mitchel, a resident of Clinton, 111., 
who sold his secret, and in a short time his followers distributed 
themselves throughout the country. It can be said, to their 
credit, that they made many remarkable cures, and that the 
treatment of piles, as well as some other forms of rectal disease, 
was taken out of the hands of reputable physicians and turned 
over to quacks. This awakened the profession to the fact that 
they were losing many patients who were able to pay good fees, 
and that if they did not expose the fraud, if it were one, or 
learn the secret, that they might give their brethren the benefit 
of it, the profession would be disgraced. Working on this line, 
Andrews, of Chicago, in 1876, obtained the secret, and, taking- 
measures adapted to the purpose, found that his information 
was correct. He then communicated with a number of itiner- 
ants, and also with a number of regular physicians who had been 
observing their practice, and ascertained that Mitchel started 
out by using one part of carbolic acid to two parts of olive-oil. 
Some of his followers tried ail kinds of astringents, but all 
returned to carbolic acid. Andrews says that the ingredients 
used were oil, glycerin, or alcohol, to which water was some- 
times added. Carbolic acid was used, from 20 to 100 per cent. 
Out of 3304 cases treated, 13 deaths were reported, besides 
numerous cases of abscesses, hemorrhages, and other complica- 
tions. Andrews has compiled the prescriptions used by the 
various itinerants in his work on rectal and anal surgery. 
After the publication of the method of the itinerants many 
reputable surgeons were overzealous in commending this 
method of curing piles. Kelsey published a report of 200 
cases so treated, claiming that the method was easy and certain, 
especially in cases of long standing, and that the piles could be 
cured without risk, pain, or delay from business. By referring 
to his recent text-book on diseases of the rectum, you will see 
that his views have materially changed, for he says : " While 



TREATMENT OF INTERNAL HEMORRHOIDS. 203 

for a year I used the method almost exclusively, I now use it 
only in selected cases." One cannot help admiring the candor 
displayed by him in recording his changed views so manfully. 
The injection method has been condemned by most of the sur- 
geons both in Europe and in America ; and all agree that it is 
not the proper treatment for piles in general, and, when used at 
all, the cases should be selected with care. We heartily concur 
in this opinion, for we have witnessed many signal failures and 
much suffering from the too promiscuous injection of pile- 
tumors. 

Class of Piles Suitable for Injection. — To be brief, we will 
state that only small, distinct, pendulous piles situated above 
the grasp of the sphincter muscle should be injected. If this 
rule is followed a cure will be effected without causing much 
suffering or any delay from business, and persons thus cured 
are ever thankful, and will show their appreciation by send- 
ing other patients. We never inject piles in the following 
conditions : — 

1. When strangulated. 

2. When inflamed. 

3. When ulcerated. 

4. When external. 

5. When large and hypertrophied. 

6. When within the grasp of the sphincter. 

One cannot be too careful in the selection of the kind of 
piles to inject, for, when it is done in a promiscuous kind of 
way, some of the following complications are likely to arise : — 

1. Much pain and swelling. 

2. Ulceration or extensive sloughing. 

3. Abscesses. 

4. Constant spasm of the sphincter. 

5. Fistula. 

6. Phlebitis. 

7. Pyemia. 

8. Long delay from business. 



204 DISEASES OF THE RECTUM AND ANUS. 

9. Permanent cure not effected. 

If, on examination, you find that the case under advise- 
ment is suitable for the injection method, inform the patient 
that there will, in all probability, be some pain for a short time 
after the operation, and that the operation may have to be 
repeated one, two, or three times, depending upon the number 
of piles present. 

Preparation for Operation. — This consists in giving some 
mild cathartic the morning previous, to be followed by an injec- 
tion of warm Castile soap one hour before the operation, to be 
sure that the bowel has been thoroughly emptied and to make 
the tumors more prominent. After placing the patient in the 
position most favorable for light, each tumor can be exposed 
separately and injected by the aid of a small hinged speculum. 
(See Fig. 4.) In performing this operation we observe the 
following rules: — 

1. Cleanse the anus and surrounding parts. 

2. Place the syringe and needle in boiling water until 
everything is in readiness. 

3. Accurately gauge the amount to be injected. 

4. Force the air out before introducing the needle. 

5. Inject the fluid slowly into the pendulous portion. 

6. Inject from two to five drops in small and five to ten 
in large piles. 

7. Leave the needle within until the pile turns white. 

8. Do not inject the tissue beneath the pile. 

9. As the needle is withdrawn pressure is made with the 
index finger to prevent the escape of the fluid and arrest 
hemorrhage. 

10. Promptly return all prolapsed piles. 

11. Make a fresh solution for each injection. 

12. Keep patient in the recumbent position for a half-hour 
after operation. 

13. Only a fluid or semisolid diet is permitted for a few 
days. 



TREATMENT OF INTERNAL HEMORRHOIDS. 205 

14. Favor the weak in preference to the strong solutions. 

15. Inject only one or two piles at a sitting. 

A good light, a suitable table, an ordinary hypodermatic 
»yringe with side-bar and needle with a long shaft, a hinged 
speculum, together with suitable dressings, are all that are 
needed in carrying out the injection method. If the syringe 
has an extension-piece, so much the better. 

Solutions to be Injected. — Almost all caustics in the vege- 
table and mineral kingdoms have been tried and have their 
respective advocates. Space forbids our giving all the formulas 
which have been highly recommended; so we shall give those 
only which we believe will render the most effectual cure. If 
we had to select any one drug, we would certainly choose car- 
bolic acid, which may be used in any strength from 3 to 100 
per cent. Kelsey uses it from 15 to 35 and 50 per cent., and 
the pure acid. Andrews* is my authority for saying that the 
secret remedy of Brinkerhoff is composed of 

R Acidi. carbolici, ^j ( 30. 0p^ grammes) ; 

Zinci cliloridi, gr. viij ( 0.52 gramme) ; 

Olei olivae, |v (150.00 c.cm.). 

The " Korick System " (from Andrews) is composed of 

R Acidi carbolici, 3ij ( 8 00 grammes) ; 

Glycerini, 3ij ( 8.00 c.cm.) ; 

Ext. ergotae fid., . 3j ( 4.00 c.cm.); 

Aquae, 3ij (8.00 c.cm.). 

The following is the painless injection of S. Green 
(Andrews) :— 

R Acidi carbolici, ,^j ( 30.00 grammes) ; 

Creasoti, gr. x ( 0.64 gramme) ; 

Acidi hydrocyanici, .... gtt. j ( 0.06 c.cm.) ; 

Olei olivae, gj ( 30.00 c.cm.). 

Mix and unite under water. 

Dr. Yount, in his little book, advises the use of 3- and 5- 
per-cent. solutions of carbolic acid, believing the weaker solution 
to be more effective than the stronger. We have used carbolic 

* Andrews, Rectal and Anal Surgery. Third edition, p. 149. 



206 DISEASES OF THE RECTUM AND ANUS. 

acid in almost every proportion and have witnessed a weak 
solution create more disturbance than the stronger solution 
used in the same way on another person. This may have been 
due to the general condition of the patient or to omitting some 
detail in the operation. Of late we have been using the fol- 
lowing formula, with which we have been very much pleased: — 

R Acidi carbolici, gr. xij (0.78 gramme) ; 

Glycerini, 3j (4.00 c. cm.); 

Aquae, 3j (4.00 ecru.). 

M. Sig. : Inject. 

We have used solutions of ergot, iron, and many astrin- 
gents, but prefer carbolic acid used in any one of the formulas 
mentioned. 

Case XXYII. — Internal Hemorrhoids Treated by the Injection 

Method. 
Mr. L. M., aged 43, banker by occupation, came to me to be treated 
for piles. He insisted that I should treat him by the injection method, 
so that he would not have to take chloroform and be detained from his 
business. On examination, I found four very large, congested piles that 
sometimes protruded. I advised a more certain and radical operation, 
but he would not submit to it. I then fully explained to him that com- 
plications might arise that would cause him some pain and delay from 
business, and, further, that I could not promise him a permanent cure; 
but that, in view of these facts, if he so desired, I would do the best I 
could for him. He instructed me to go ahead with the treatment. The 
bowel was washed and he was requested to bear down ; the tumors were 
cleansed with a carbolized solution and made ready for the injection, 
which was made as follows : — 

An hypodermatic s} r ringe, with an extension-piece and needle, was 
boiled and filled with the following solution, which has served me as well 
as any other : — 

R Acidi carbolici, . . . . . gr. xij (0.78 gramme) ; 
Glycerini, 
Aqua?, aa 3j (4.00 c.cm.). 

Ten drops were injected, respective^, into two of the tumors. The 
needle was not withdrawn until they turned whitish in color. Then 
they were oiled, replaced, and the patient requested to remain quiet in 
the recumbent position for an hour or so. For a few moments he suf- 
fered considerable pain, but at the end of two hours he returned to the 



TREATMENT OF INTERNAL HEMORRHOIDS. 207 

bank, wrote two letters, and went home and made himself comfortable. 
During the night he felt restless and uncomfortable about the rectum, 
but had no acute pain. I saw him on the third day at my office and he 
complained of nothing but heat and fullness about the anus. I deemed it 
best not to make an examination, for the reason that, if the piles should 
become protruded, his suffering would be increased and a cure delayed. 
He was restricted to a liquid diet and the bowel was opened every other 
day with a saline cathartic. On the tenth day the tumors were almost 
completely shriveled up. At this time the remaining two were injected 
in exactly the same way as the previous ones. During the night he 
complained of considerable pain and could not get relief, though poultices 
were applied constantly to the anus. At 2 a.m. and 4 a.m. he had one- 
fourth grain of morphia, which afforded him some relief. The pain con- 
tinued on the second and third days and, in addition, all the symptoms 
of an inflammatory process were present. By separating the anal folds 
the mucous membrane appeared red and swollen and there was every 
evidence that an abscess was forming. His pulse was 100 and full; 
temperature, 103° F. He was restless and constantly complained of pain 
and twitching of the sphincter muscle. The poultices were continued. 
On the sixth day the abscess pointed a little below and to the right of 
the anus. It was promptly incised, curetted, irrigated, and packed with 
iodoform gauze. The relief was instantaneous, in so far as the pain was 
concerned. While he was under the anesthetic I made a thorough 
examination to ferret out the cause of the inflammatory process. 

I found that one of the tumors had become indurated and shriveled 
up as the former ones had done, while the other had undergone a slough- 
ing process ; and in the centre of the tumor where the injection had been 
made was a deep, irregular, inflamed ulcer, at the bottom of which I 
found a small, round, hard lump of fecal matter. The question then 
arose in nr^ mind as to whether the septic condition was induced hy an 
unclean needle, the solution used, or as a result of a slough caused by 
the solution's becoming infected by the fecal matter at a later elate. I 
am inclined to believe that the last is the most probable solution to the 
question. The parts were cleansed daily with a bichloride solution and 
the abscess-cavity packed with gauze. My patient was confined to his 
bed for seven days and detained from his business for ten, — a longer time 
than if he had submitted to the radical operation, and his suffering was 
much more severe. At the same time he narrowly escaped having to 
undergo an operation for fistula. 

We record this case to show one of the many complica- 
tions that sometimes follow the injection treatment of piles. In 



208 DISEASES OF THE RECTUM AND ANUS. 

conclusion, we will say that if everything goes on well such 
patients are able to attend to their usual duties while under- 
going treatment with scarcely any inconvenience; and, further, 
that a permanent cure is sometimes effected. It is the uncer- 
tainty of this method, however, that condemns its promiscuous 
use in the treatment of piles. 

whitehead's operation for piles by excision. 

Mr. Walter Whitehead, of Manchester, England, in the 
February number of the British Medical Journal of 1887, after 
criticising such tried operations as the clamp and cautery and 
the ligature, describes the operation of excision which bears his 
name and reports complete success in three hundred consecutive 
cases without a single death, secondary hemorrhage, abscess, 
ulceration, stricture, or incontinence. He describes the opera- 
tion as follows : " By the aid of scissors and a pair of dissecting 
forceps the mucous membrane is divided at its junction with 
the skin around the entire circumference of the bowel, every 
irregularity of the skin being carefully followed. The external 
and the internal sphincters are then exposed by rapid dissection 
and the mucous membrane and the attached hemorrhoids, thus 
separated from the submucous bed upon which they rested, are 
pulled bodily down, any undivided points of resistance being 
snipped and the hemorrhoids brought below the margin of the 
skin." The mucous membrane above the hemorrhoids is now 
divided transversely in successive stages and the free margin of 
the severed membrane above is attached as soon as divided to 
the free margin of the skin below by a suitable number of silk 
sutures, which he does not remove. He prefers the lithotomy 
position and uses torsion to arrest hemorrhage in preference to 
the ligature. Mr. Whitehead claims that piles are not indi- 
vidual tumors, but that they are only a part of the general 
plexus of the veins associated with the superior hemorrhoidal, 
each radicle being similarly, if not equally, affected by the initial 
cause, either constitutional or mechanical. He believes that all 



TREATMENT OF INTERNAL HEMORRHOIDS. 209 

vessels should be exposed, and that the entire pile-bearing area 
should be removed. The operation has not become general 
either in this country or in England ; in fact, few, if any, perform 
this operation for either an ordinary or a bad case of piles. We 
have performed the operation only six times up to the present 
date, and, from the little experience we have had with it, we feel 
certain that there are better and simpler operations that can be 
resorted to, that cause much less suffering, that are more quickly 
recovered from, and the cure obtained is quite as effective. We 
witnessed this operation performed by a certain surgeon, who, 
to all appearances, did it simply to make a surgical display, for 
there were only one or two small tumors and the ligature or the 
clamp and cautery would have done quite as well. In discussing 
this operation with one of the surgeons of the Edinburgh Infirm- 
ary who was an advocate of it, we asked him whether, if he had 
piles, he would have Whitehead's operation performed on himself. 
He replied by saying that was a different matter, and in such a 
way as to lead us to believe that he would never submit to it. 
When endeavoring to decide on the operation to perform in a 
given case, select the one you would have done if you were in 
the patient's place. The operation under consideration certainly 
deserves a place in rectal surgery, but not so prominent a one as 
Mr. Whitehead would lead us to believe. We cannot commend 
it for the treatment of ordinary or even bad cases of piles, for 
two reasons : first, they can be cured by a less difficult operation ; 
second, complications frequently accompany and undesirable 
results may follow the operation. We heartily indorse the 
operation in long-standing cases, accompanied by frequent 
hemorrhages, where there are no distinct pile-tumors, but where 
the veins of the entire rectal wall are engorged and extensively 
dilated from the external sphincter upward for two or three 
inches (5 to 7.6 centimetres). When such a condition is present 
nothing short of the removal of the entire diseased area will 
effect a cure. The following are some of the advantages of the 
operation as claimed by Mr. Whitehead, viz. : — 



210 DISEASES OF THE RECTUM AND ANUS. 

1. That it is the most natural method, and is in perfect 
harmony with surgery. 

2. Excision, in addition to its simplicity, requires no instru- 
ment not found in an ordinary pocket-case. 

3. It is a radical cure. It removes the peculiar pile-bearing 
area. He believes recurrence to be impossible. 

4. It is not more dangerous than other methods recom- 
mended for the removal of piles. 

5. Pain is less severe than that following any other opera- 
tion. 

6. The loss of blood during the operation probably exceeds 
that of the ligature or clamp and cautery, but the dangers of 
secondary hemorrhages are unquestionably less. 

We will now name some objections which have been 
made by different operators, and then we feel quite certain 
that the reader will agree with us that the operation should 
not be resorted to except in extreme cases, as previously men- 
tioned : — 

1. It is difficult and bloody. 

2. It requires a much longer time to perform, — from thirty 
to fifty minutes, — while the clamp and cautery or ligature 
requires only five or ten. 

3. Pain is severe and continues several days. 

4. There is danger of ulceration and stricture from non- 
union. 

5. There is danger of ulceration and abscess from unre- 
in oved sutures. 

6. A much longer time for recovery than from other oper- 
ations is required. 

7. It is not suitable when other complications are present. 

8. It is not suitable except in selected cases. 

9. Lastly, piles can be cured quite as well by other, safer, 
and milder operations. 

We wish to emphasize the danger of a stricture's follow- 
ing this operation, for we have treated four during the past year. 



TREATMENT OF INTERNAL HEMORRHOIDS. 211 

Following as a result of non-union and retraction of the mucous 
membrane there was a broad, circular, ulcerated band. Pratt, 
in his " Orificial Surgery," describes an operation which is none 
other than the " Whitehead," with slight modifications. This 
operation he designates " The American Operation," and would 
lead his followers to believe that it was of recent origin and 
originated by himself, when the credit belongs to Mr. White- 
head. 

LIGATURE. 

This operation stood the test of time for hundreds of years 
before the birth of the Saviour. It comes down to us recom- 
mended by such ancients as Hippocrates, Celsus, and Rhazes, 
the great Arabic physician of the tenth century, and many 
others. The great majority of authors in later years, and up 
to the present day, commend it as being the best operation for 
the cure of hemorrhoids. For instance, we find it indorsed by 
Sir Astley Cooper, Burke, Cripps, Van Buren, Bodenhamer, 
Syme, Allingham, Mathews, and others. There is no question 
but this operation is pre-eminently the best for ordinary cases of 
piles, with one exception, — namely, the clamp and cautery. The 
results that have followed both of these operations have proven 
that they are deserving of the highest praise and a detailed 
consideration. The reader may choose the one he can perform 
with the most satisfactory results, with the assurance that a 
radical cure will be effected. 

The ligature operation, as performed by the ancients, re- 
sembles the operation of to-day in many respects. Galen 
recommended the excision of that portion of the pile external 
to the ligature. Others simply placed a ligature around the pile 
and let it slough, w 7 hile some transfixed the centre of the pile 
with a double ligature and tied it on both. sides. The surgeons 
of to-day differ as to the best method of applying the ligature. 
The majority, however, prefer the operation which was devised 
by the late Mr. Salmond and popularized by Allingham, Si\, as 
is done at St. Mark's Hospital, London. This operation has 



212 DISEASES OF THE RECTUM AND ANUS. 

been practiced in that institution for the last fifty years. Mr. 
Ailing-ham describes it as follows : — 

The patient, having been previously prepared by purgation, 
is placed on the right side of a hard couch in a good light, 
and is completely anesthetized. The sphincter muscle is then 
completely, but gently dilated. This completed, the rectum 
for three inches (7.6 centimetres) is within easy reach, and no 
contraction of the sphincter takes place ; so that all is clear like 
a map. The hemorrhoids, one by one, are taken by the surgeon 
with a vulsellum, catch-tooth, Pratt's "T," or Mathews's pile- 
forceps or pronged-hook fork and drawn down. He then, with 
a pair of sharp scissors, separates the pile from its connection 
with the muscular and submucous tissues upon which it rests. 
The cut is to be made in the sulcus or white mark which is 




Fig. 66.— Thomas's Curved Tissue-Forceps. 

seen where the skin meets the mucous membrane, and this in- 
cision is to be carried up the bowel and parallel to it to such a 
distance that the pile is left connected by an isthmus of vessels 
and mucous membrane only. There is no danger in making 
this incision, because all the larger vessels come from above, 
running parallel with the bowel, just beneath the mucous mem- 
brane, and thus enter the upper part of the pile. A well- 
waxed, strong, thin, plaited silk ligature (Turner's No, 8) is 
now to be placed at the bottom of the deep groove made, and 
the assistant then draws the pile well out. The ligature is tied 
high up at the neck (see Fig. 67) of the tumor as tightly as 
possible. Great care must be exercised in tying the ligature. 
The operator should be equally careful to tie the second knot 
so that no slipping or giving way can take place. If it is ad- 
visable 1 , tie a third knot, for the secret of the well-being of the 
patient depends greatly upon this tying, — a part of the operation 



TREATMENT OF INTERNAL HEMORRHOIDS. 



213 



by no means easy to effect (as all practical men know). If this 
is done, all the large vessels in the piles must be included. The 
arteries in the cellular tissues around and outside the lower 
bowel are few and small, and do not assist in the formation of 
the pile, being outside it. The silk should be so strong that the 
operator cannot break it by fair pulling. If the pile is very 
large, a small portion may now be cut off, taking good care to 
leave sufficient stump beyond the ligature to guard against its 




Fig. 67.— Correct Method of Applying the Ligature 

slipping. When all the hemorrhoids are thus tied they should 
be returned within the sphincter. After this is done any super- 
abundant skin which remains apparent may be cut off; but it 
should not be too freely excised, for fear of contraction when 
the wound heals. We always place a pad of wool over the 
anus, and a tight T-bandage, as it relieves pain most materially 
and prevents any tendency to straining. 

To secure a cure by the ligature it is not essential to follow 
in detail the various steps as just recorded. The lithotomy 



214 



DISEASES OF THE KECTUM AND ANUS. 



position, with the limbs well flexed on the abdomen and held in 
position by Clover's crutch (see Fig. 68), presents a better view 
of the parts after the sphincter has been divulsed. Sitting 
upon a high stool in front of the patient, the operator has the 
tree use of his hands, and can apply the ligature with more case 
and in a shorter time than when the patient is placed on the 




Fig. 68.— Clover's Crutch. 

side. After all of the piles have been ligated and those portions 
external to the ligature cutoff, they should be placed within the 
bowel. Patients suffer considerably for the first twenty-four 
hours. The pain during the second and third days is frequently 
quite annoying, though in some cases it may be very slight. 
The lower part of the rectum presents a sensation of heat and full- 



TREATMENT OF INTERNAL HEMORRHOIDS. 



215 



ness. Patients are often awakened after the operation by sudden 
contractions of the levator ani, and the strangulated tumors 
seem to act as foreign bodies, keeping up the irritation. The 
ligatures will ordinarily slough off from the seventh to the ninth 
clay, but now and then they have to be removed by the surgeon. 
We assisted in the removal of one, the patient being chloroformed 
for the purpose, in the Western Hospital for Rectal Diseases, in 
London, three years ago ; in this case the pedicle was unusually 
large and the ligature cut only about half-way through. The 
pile was seized with forceps and detached with scissors. We 
are inclined to think that this complication occurs more fre- 
quently than the friends of the ligature would have us believe, 
and in such cases increased pain and delayed healing are always 




Mathews's Pile-Forceps. 



noticeable. The time required to remain in -doors in such cases 
varies from three to six weeks. As a rule, patients operated on 
by the ligature are able to be about in from two to three weeks, 
although the ulceration may not be entirely healed. In St. 
Mark's Hospital the death-rate from all cases in internal hem- 
orrhoids by ligature for more than fifty years has been about 
one in a thousand. This is undoubtedly a fine showing, con- 
sidering that they were all hospital patients. Four died there 
of tetanus during March and April, in the year 1858, but none 
since. This would indicate an epidemic of tetanus during that 
time. Many other operators have met with equally good suc- 
cess. This fact, coupled with the permanent cure which follows 
this operation, has won for it a very enviable reputation. We 
are free to admit that this operation is a very good one, indeed, 



216 



DISEASES OF THE RECTUM AND ANUS. 



and that the results have been as good as from any other yet 
devised. At the same time, we believe there is one other oper- 
ation, to be described presently, that will be followed by just as 
good results, from which patients suffer much less, recover more 
quickly, and with as few bad results as follow the ligature. We 
refer to the clamp-and-cautery operation. 

CLAMP-AND-CAUTERY OPERATION. 

This operation was originated by Mr. Cusack, of Dublin ; 
it was introduced into London by Mr. Henry Lee, and later 




Fig. 70.— Paquelin Cautery. 

brought prominently before the profession in England by Mr. 
Henry Smith, while delivering lectures before the Medical So- 
ciety of London during the winter of 1864 and 1865. He had 
previously performed the operation many times. Up to the 
date of the origin of this operation the ligature was used uni- 
versally throughout Great Britain. Through the instrumen- 
tality of Mr. Smith many were induced to use the clamp and 
cautery, and the majority who gave it a fair test were much 
pleased with the results. It is popular in Germany ; but in 




PLATE XV. -AUTHORS CLAMP ADJUSTED AND SCISSORS 
IN POSITION FOR EXCISION DF HEMORRHOIDS. 



:; = FBthdgE Co Lith Phila. 



TREATMENT OF INTERNAL HEMORRHOIDS. 217 

America it is a question which is the more popular, the clamp 
and cautery or the ligature, both having many friends of equal 
ability to judge. We are free to say that we give preference to 
the clamp-and-cautery operation. At the present time we have 
at our command many admirable clamps, the very popular 
Paquelin cautery and the cautery irons. (See Fig. 70.) By 
the aid of these the operation can be performed with rapidity ; 
and, when used with care, it is not a barbarous procedure, as is 
often claimed, but a scientific surgical operation, whereby only 
the diseased tissue is removed. The pain which follows the 
clamp-and-cautery operation is less than that of any other oper- 
ation for piles. There are four steps in the operation. 1. The 




Fig. 71.— Smith's Clamp. 

sphincter muscle should he thoroughly divulsed in every direc- 
tion. (See Fig. 72.) This will cause the piles to come quite 
prominently into view. Each in turn is seized with a vulsellum 
or catch-tooth forceps and drawn well down. 2. The mucous 
membrane and skin should be severed, and, next, the pile 
should be dissected upward. (See Fig. 73.) 3. The clamp 
should be adjusted firmly to the base of the tumor, and with a 
pair of scissors that portion external to the clamp should be 
excised. (See Plate XV.) 4. Every portion of the stump 
should be thoroughly cauterized with the cautery-point at a 
dull-red heat, after which the clamp should be loosened to see 
if bleeding occur. (See Fig. 74.) If it does, the operator 
should re-adjust the clamp and cauterize all bleeding points. 



218 



DISEASES OF THE RECTUM AND ANUS. 



After all the piles have been removed in this way the 
rectum should be irrigated and carbolized vaselin applied to the 
cauterized surfaces. A wedge-shaped compress should be 
placed over the anus and kept in place by a well-adjusted 
T-bandage. We have, of late, been in the habit of separating 
the mucous membrane and skin, after which the pile is dissected 
off the submucous tissue just as in ligature operation. The 
clamp is adjusted at the bottom of the sulcus thus produced. 
In this way there is no danger of cauterizing the skin ; conse- 




Fig. 72.— Dilatation of the Sphincter Ani. 

quently, there will be little pain after the operation. When the 
piles are small or situated high up and cannot be drawn down 
and clamped, the narrow cautery-blade should be drawn once 
or twice across each pile ; this will cause them to shrink up. 
The cautery may be applied, if used with discretion, to any 
dilated veins present that might at some future time form piles. 
As regards this operation, we think it preferable to the ligature; 
not because the cure is more effective, the pain so much less, or 
the operation less difficult to perform, but because of the facts 



TREATMENT OF INTERNAL HEMORRHOIDS. 



219 



that the operation can be performed more quickly, with greater 
ease and accuracy, and the patient's recovery is from six to eight 
days earlier than after the ligature. At least, such has been 
our experience. When the ligature has been applied ordinarily 
it will not slough off before the eighth day ; and, when it does, 
it leaves an ulcer with irregular edges, which not un frequently 
has a tendency to become chronic. At best, patients are rarely 
able to be about the room before the tenth day, and frequently 




Fig. 73. — Severing the Mucous Membrane from the Skin. 



not for two weeks ; while after the cautery operation the ulcer 
will be clean and smooth the day of the operation, and will be 
almost healed by the time the ligature has sloughed off. 
Patients are allowed to sit up on the third day, and it is a rare 
occurrence if they be detained from business more than a week. 
In many cases the time that is saved is represented by the length 
of time that it requires for the ligature to come aivay. Gran ting- 
that some healing takes place while the ligature is sloughing 
off, we believe that it will require as long for the remaining 



220 



DISEASES OF THE RECTUM AND ANUS. 



portion of the ulcer to heal as after the cautery operation ; for 
the ulcerated surface after the latter seems to heal more readily 
than after the former operation. The pain after the cautery 
operation amounts to nothing if care has been used to avoid 
cauterizing the shin ; but when it has been touched, if only 
slightly, the pain is exceedingly annoying. Retention of urine 
occurs sometimes, but not so frequently as after the ligature. 
We have never had a case die from hemorrhage during or after 




Fig. 74.— Cauterizing the Stump. 



the operation. Bleeding sometimes occurs at non-cauterized 
points when the clamp has been removed ; it is then applied 
again until all oozing stops, after which the patient may be 
placed in bed with as much safety as if each vein had been 
ligated. It has been our experience that hemorrhage will occur 
more frequently from the slipping of the ligature, when it or the 
stump has been severed too closely, than after the clamp-and- 
cautery operation. It is not probable that either tetanus or 
pyemia will follow the cautery operation, for there is no con- 



TREATMENT OF INTERNAL HEMORRHOIDS. 221 

striction of terminal nerve-filaments and the danger of sepsis 
has been minimized by searing the exposed surfaces. So far as 
a radical cure is concerned, the cautery and the ligature oper- 
ations are on a level, for when either one has been performed 
as previously described a permanent cure will follow in every 
case. 

The Author's Pile and Polypus Clamp. — In this connection 
we wish to describe a new clamp, which we have used to the 
exclusion of all others during the past year. It has done such 
admirable work that we feel justified in commending it to the 
profession. (See Fig. 75.) For a long time we have been 
dissatisfied with the pile-clamps on the market, for the reason 
that they do not exert equal pressure along the entire length 
of the blades ; and, as a result of this imperfection, we came 
near losing two patients from hemorrhages. Other clamps, as 
Kelsey's, Smith's, Langenbeck's, etc., are made like a pair of 
scissors, having a rivet near the heel of the blade, and when the 
tumor is grasped that portion nearest the heel is held tightly and 
that near the tip loosely or not at all. (See Fig. 75, B, C, and D.) 
Consequently, when that portion of the tumor external to the 
clamp is cut off, all of the tissues except those nearest the heel 
slip through before the operator has a chance to cauterize them, 
thus subjecting the patient to the danger of a serious, if not 
a fatal, hemorrhage. Our clamp differs materially from the 
others (see cut, A.); it is so constructed that the blades are at 
right angles to the handle. This insures their remaining parallel 
and distributing equal pressure at every point, no matter how 
far they may be apart ; so that not even the slightest portion 
of the tumor can slip through and escape cauterization. This 
practically makes a hemorrhage after the clamp-and-cautery 
operation an improbable, if not impossible, occurrence. The 
following are some of the good points claimed for this clamp : — 

1. It is neat and attractive. 

2. It is aseptic. 

3. It is strong and does not spring nor get out of order. 



000 



DISEASES OF THE RECTUM AND ANUS. 



4. It can be adjusted quickly and with perfect ease. 

5. It does not obstruct the operator's view. 

G. It has a strong spring that separates the blades and a 
screw with a double thread, and a tap on the nut is sufficient to 
run it from top to bottom. 

7. When operating high up the bowel it not only does the 
work of a clamp, but that of a speculum as well. 




Fig. 75.— Author's Pile and Polypus Clamp. 

The letters show the dillereut damps and their clamping power. A, Gant's; B, Kelsey's; 
C, Smith's ; I), Langenbeek's. 



8. It can be used as well with the patient in one position 
as in another. 

9. It is as well suited for the removal of piles high up in 
the bowels as when they are protruded. 

10. It is admirably adapted for the removal of rectal polypi. 

11. It can be used for the removal of polypoid growths in 
the vagina. 



TREATMENT OF INTERNAL HEMORRHOIDS. 223 

12. It is especially adapted for the removal of a section of 
the bowel in cases of prolapsus recti when the cautery is indi- 
cated or sutures used. 

13. It makes an admirable colotomy clamp. It causes the 
segment of gut to slough off in three or four days with little 
pain and no bleeding. 

14. When it is desirable to crush piles, it can be substituted 
for the pile-crushers now in use. 

15. It is the best clamp made, for the reason that it exerts 
equal pressure at all points and under all conditions. 

SUBMUCOUS LIGATION. 

Dr. Merrill Rickets, of Cincinnati, has devised a new oper- 
ation for hemorrhoids which is performed after the following 
method : After thorough divulsion of the sphincters a large 
semicircular needle with silk ligature is introduced subcutane- 
ously from the muco-cutaneous line to the upper border of the 
pile-bearing area and then returned to make its exit at the 
point of entrance. The needle is then removed and the ligature 
made taut above the venous plexus and the ends left hanging- 
out. These ligatures may be from one-half to one inch (1.3 to 
2.54 centimetres) apart, as the case may require. It is not nec- 
essary to tie all the varices in this operation, as the atrophic 
changes will necessarily obliterate the remaining ones. No 
tissue is sacrificed ; the mucous membrane remains intact ; there 
is no hemorrhage, infection, nor pain of consequence, and the 
loss of time is practically nil. 

While the operation is absolutely radical and without any 
serious consequences, the sutures are allowed to come out of 
their own accord. The operation thus far, he says, has proved 
a success, and patients have suffered very little pain during the 
life of the ligature. 

This operation is new and the author, like many surgeons, 
has not had a chance to test it in a suitable number of cases to 
commend it. It seems a plausible operation where the tumors 



224 DISEASES OF THE RECTUM AND ANUS. 

are few and small, but in bad cases where there is a great 
redundance of tissue we should expect to meet with failure. 
Again, there is no reason why an abscess and fistula might not 
follow as a result of the sutures' being left, as is the case so 
often after the Whitehead operation. 

AFTER-TREATMENT. 

The after-treatment of operations for piles is of much im- 
portance. After any operation for piles a well-adjusted pad to 
the anus, held in place by a T-bandage, supports the parts and 
renders the patient more comfortable, and tends to arrest any 
bleeding that might otherwise take place. We do not believe 
in the use of suppositories, although many high in authority 
recommend the immediate introduction of suppositories con- 
taining morphia, opium, belladonna, etc., for the relief of pain. 
As a rule, they will produce an uncomfortable feeling and cause 
the patient to strain in his endeavors to force them out. When 
we are compelled to use anything for the relief of pain we 
prefer an hypodermatic injection of one-fourth grain of mor- 
phine. Ordinarily, this will not have to be repeated. When 
the pad applied to the anus becomes dry and hard, the anus 
should be sponged off with warm water and a new pad applied. 
If the patient has been purged before the operation, it is not 
necessary to tie up the bowels with opium, for they will not 
move before the third day, and frequently not then of their own 
accord. In case they do not, a Seidlitz powder or a dose of 
salts, which act admirably, should be given. If there is reason 
to believe the feces are hard, an injection of soap-suds should 
be given to soften them. Patients should be urged to remain in 
bed until the ulcerations have almost or entirely healed. Then, 
when the patients begin taking active exercise, the danger of 
the ulceration's becoming chronic will be slight. The ulcerated 
surfaces should be cleansed daily, and, if there is the least ten- 
dency to become chronic, an application of calomel or silver 
nitrate (fifteen grains to the ounce) will stimulate the bowels to 



TREATMENT OF INTERNAL HEMORRHOIDS. 225 

renewed action. In case of retention of urine, hot stupes or 
poultices should be applied over the pelvis. This will make 
the patient more comfortable, and not infrequently enable him 
to void his urine independently of the catheter. If a catheter 
is used, a soft-rubber one is preferable, but should be cleansed 
in boiled, filtered water before and after each introduction. The 
diet after an operation should be confined to liquids and semi- 
solids for the first four or five days, but patients should have 
plenty of nourishing soups, beef-tea, soft-boiled eggs, etc. 
Patients do much better if they have a bright, cheerful room 
and congenial company. Under unpleasant surroundings they 
become dissatisfied and worry over their condition, although 
everything may be all right. 

Prognosis. 
After patients have recovered they frequently ask if they 
will ever have piles again. This is a difficult question to 
answer, for there are many things to take into consideration. 
One can say positively that those piles which have been oper- 
ated upon will never return, but whether others will present 
themselves depends not only upon the operation selected and 
the thoroughness with which it is performed, but perhaps more 
upon the causes of the piles in the first place. When they are 
a symptom of some other condition, — as a disordered liver, 
obstructed circulation, stricture, retroverted uterus, etc., — a 
relapse may occur, unless the cause is removed at the same 
time the piles are operated on. When persons have been dis- 
charged before the ulceration has entirely healed, bleeding may 
follow an action ; but they can be assured of their ultimate 
recovery. From experience, and by observation of patients 
previously subjected to any of the operations heretofore advo- 
cated, we can say that the recoveries have been eminently 
pleasing in uncomplicated cases, and that a recurrence is quite 
the exception ; in fact, we have never operated twice on the 
same patient. There is no class of operations which proves 



2'26 DISEASES OF THE RECTUM AND ANUS. 

more gratifying to the surgeon ; these patients are ever grateful, 
not so much for the relief of the pain and Weeding as for the 
mental relief obtained, for it is a well-known fact that, from a 
surgical point of view, in such cases, the mental worry is out 
of all proportion to the importance of the disease. 

ILLUSTRATIVE CASES. 

Case XXVIII. — Internal Hemorrhoids Complicated with Prolapse. 
Clamp-and-Cautery Operation. 

This patient, a merchant 40 years old, and a man of exemplary 
habits, said he had suffered for several years with piles. Recently, how- 
ever, they came down to such an extent as to interfere with his business. 
Examination revealed the presence of a mass which proved to be the 
lower portion of the rectal wall. He was given an enema and requested 
to bear down. Immediately a number of very large hemorrhoids came 
into view, forming a beautiful rosette. The patient was sent to All-Saints 
Hospital to be prepared for the operation, which was performed on the 
following afternoon, as follows : The sphincters were first thoroughly 
divulsed ; then each tumor was in turn seized with catch-forceps, pulled 
down, the skin and mucous membrane severed, the clamp (author's) ad- 
justed in the incision, the tumors pulled farther down, and the clamp 
tightened. Then that portion external to the clamp was excised and the 
stump cauterized with a Paquelin cautery-point and the clamp removed. 
The cautery was applied to the mucous membrane and external sphincter 
to insure sufficient contraction to prevent a recurrence of the prolapse. 
The rectum was then irrigated and dusted over with iodoform, after which 
gauze and cotton were placed against the anus and held in position by a 
snug T-bandage. He recovered from the anesthetic nicely and was 
able to pass his urine three hours after the operation without any 
assistance. 

Early in the night he became restless and complained of slight 
pain ; the bandage was loosened, and in a short time he went to sleep 
and slept nearly all night. Once or twice he was awakened by a sudden 
jerking about the anus, — a symptom of common occurrence after opera- 
tions for hemorrhoids. This is probably due to the levator ani. His 
bowels did not act until the fourth day, after a dose of Epsom salts had 
been administered. After each stool the rectum was irrigated and the 
gauze applied after the raw surfaces had been painted over with balsam 
of Peru. His diet consisted of liquid and semisolid foods. At the 
end of the first week the patient was able to walk about with comfort ; 



TREATMENT OF INTERNAL HEMORRHOIDS. 227 

he was discharged from the hospital and returned to his home. He was 
instructed to cleanse the rectum daily, use the balsam, and write me in a 
week. He obe3 T ed instructions, and said he had resumed his duties and 
that he should not know that he had been operated on except for a 
slight tenderness about the anus. 

Case XXIX. — Internal Hemorrhoids Complicated with 
Ulceration. Ligature Operation. 

Mrs. S., the wife of a prominent wholesale merchant, was referred 
to me to be treated for a rectal disease. She informed me that she had 
been rendered almost helpless from daily hemorrhage from the rectum 
that followed each action ; and, in addition to this, she had considerable 
pain of late, which she thought was due to two tumors that remained 
constantly outside the anus. Until the beginning of her present illness, 
one 3^ear ago, she had enjoyed perfect health and w r eighed 140 pounds, 
while now she weighs only 108. 

Examination revealed two large internal hemorrhoids, just without 
the anus, that were ulcerated and exceedingly sensitive. The sphincter 
remained passive, probabty being tired out, as it were, from the constant 
contraction and irritation. An enema w T as administered, and she was 
requested to strain down. Immediately the tumors became distended 
and commenced to bleed, and the blood could be seen spurting from the 
centre of the ulcerated spots in two of the tumors. 

Operation. — I advised her to have them operated on without delay, 
and, further, that I preferred the clamp-and-cautery operation. The 
idea that the cautery w^as to be applied frightened her ; she asked me to 
do the ligature operation, for a friend of hers had been operated on in 
this manner with success. I consented, and each tumor was, in turn, 
seized, pulled down, the skin severed near the muco-cutaneous junction, 
and the piles dissected up from the submucous tissues and ligated high 
up. A small amount of cotton smeared over with vaselin was then 
passed into the rectum and the patient put to bed. 

In one hour she was conscious and was suffering very little pain. 
At 8 p.m., six hours after the operation, she became very restless; she 
said the rectum felt hot, swollen, and pained her very much. Cold 
cloths were applied to the anus, but gave no relief; so I ordered one- 
fourth grain of morphine hypodermatically, which gave some relief, but 
had to be repeated in two hours, after which she had a fairly comfortable 
night. She was unable to void her urine, though hot stupes had been 
applied, and it was removed b}' catheter. Next morning she was fairlj- 
comfortable, but the urine had to be drawn for four da} T s afterward. 
From the fourth day she complained of nothing but a fullness about the 



228 DISEASES OF THE RECTUM AND ANUS. 

rectum and a feeling as if something were there that should come away, 
— a symptom that I have frequently observed after this operation. The 
Ligatures came away, respectively, on the seventh and the ninth days, 
leaving grayish-looking ulcers with irregular edges. These were treated 
with one or two applications of calomel, to clear them of any remaining 
portion of the slough. Afterward they were treated like any other 
ulceration, — namely, by cleanliness, stimulating applications, and rest. 
She was up and about at the end of the second week, and at the end of 
the third she was discharged from the hospital cured. 



CHAPTER XX. 

HEMORRHAGE FROM THE RECTUM. 

Hemorrhage from the rectum constitutes one of the most 
frequent and alarming symptoms of rectal diseases, often being 
the first indication that anything is wrong about the rectum. 
Blood may be voided pure or mixed with pus, mucus, feces, or 
other debris. The discharge of blood occurs during stool, and 
may continue for a greater or less length of time afterward. 
Bleeding is not a sure indication that piles are present. It may 
be a symptom of 

1. Ulceration. 4. Polypi. 

2. Fissure. 5. Malignant disease. 

3. Stricture. 6. Injuries to the rectum. 

It may be very slight or profuse. Sometimes patients 
bleed almost to death from some trivial lesion, unless the bleed- 
ing is promptly arrested. The means resorted to for arresting 
hemorrhage after an operation about the rectum are almost 
identical with those adopted for stopping the bleeding from 
other causes and in other parts of the body ; consequently, 
hemorrhages of the rectum, from whatever cause, will be con- 
sidered under the following general heading : — 

Post-operative Hemorrhages. 
Hemorrhages after operations on the rectum, like those 
occurring in other parts of the body, may be either 

1. Primary. 2. Recurrent. 3. Secondary. 

In all operations where cutting is necessary, bleeding may 
be expected, though ordinarily it will not be profuse, except in 
cases of excision of the rectum, operations for stricture, and 
extensive fistulas. 

Primary. — This variety occurs during the operation, and 

(229) 



230 DISEASES OF THE RECTUM AND ANUS. 

can be arrested by a ligature if a large vessel is involved, and 
by torsion, styptics, or cauterization if medium in size. When 
it seems to be general, or the result of oozing from a number 
of distinct points, it can be arrested by a sponge or piece of 
gauze, saturated with ice-cold or hot water, firmly pressed 
against the bleeding parts. 

Recurrent. — A more serious form of hemorrhage occurs 
where some vessel was injured during the operation and did not 
bleed at the time, was overlooked, or from the slipping of a 
ligature. This variety is known as recurrent hemorrhage and 
takes place within a few hours after the operation. 

Secondary. — Secondary hemorrhage occurs several days 
after the operation, — usually from the fifth to the eighth day, — 
as a result of some vessel's not becoming obliterated as the liga- 
ture sloughs off, or from sloughing or ulceration from other 
causes. Secondary hemorrhage occurs more frequently in de- 
bilitated and anemic patients than in those who are robust. As 
a rule, the bleeding comes on suddenly and is very profuse, and 
unless arrested immediately it may prove fatal. After rectal 
operations the nurse should be instructed to look out for the 
general symptoms of hemorrhage, for the bleeding may be 
internal and fatal, while not the slightest amount of blood 
escapes from the anus. Before mentioning the different ways 
of arresting bleeding, we desire to mention the fact that both 
patient and nurse may become unnecessarily alarmed at times, 
because the cotton and pad over the anus may become saturated 
with a red fluid.. This is likely to occur in any case where all 
of the irrigating fluid is not removed from the rectum at the 
close of the operation. Close examination, however, reveals it 
to be a thin, watery fluid, and not pure blood. If, on the other 
hand, you find that there is an active hemorrhage, first thor- 
oughly prepare yourself with the things with which to stop it, 
then go at it in a business-like manner, for it is exceedingly 
dangerous to tamper with hemorrhage by doing some little thing 
and trusting to luck that it lias stopped and will not occur 



HEMORRHAGE FROM THE RECTUM. 231 

again. We were once called to a man who had been bleeding 
from the rectum at intervals for several days. Rest in bed, the 
application of nitric acid, and styptics had been tried thoroughly 
and failed to arrest the bleeding. When we arrived the patient 
was livid, pulseless, and unconscious. They told us his bowels 
had just acted; the motion was examined and it contained 
nothing but clotted blood. The physician present thought we 
were too late. We at once introduced a large speculum and 
found a large rectal ulcer, one inch (2.54 centimetres) in circum- 
ference, in the centre of which could be seen the bleeding-point, 
which was immediately cauterized with a Paquelin cautery- 
point and the ulcer treated with silver. Hot baths and stimu- 
lants soon revived the patient, who improved from that time on. 

Methods of Arresting Hemorrhage. 
The methods of arresting hemorrhage are many. Those 
found to be most reliable are : — 

1. Ligation. 4. Compression. 

2. Cauterization. 5. Styptics. 

3. Torsion. 6. Application of hot or cold water. 

When internal bleeding is suspected, the patient should be 
requested to empty his rectum. If bleeding has been going on, 
clots of blood will be discharged with the feces. When there 
is reason to believe the bleeding is due to a small vessel or to 
oozing, it can frequently be arrested by simply tightening the 
bandage. If this fail, the rectum should be irrigated for several 
minutes with cold or quite hot water, or with some one of the 
various astringent solutions, as alum-water, the infusion of 
black-oak bark, etc. Astringent powders dusted over the 
bleeding parts, tannic acid, gallic acid, zinc, Monsell's powder 
and other powders known to have a contracting effect on the 
tissues have all been recommended. Monsell's powder has 
been used more frequently than the others, but it has proved 
very undesirable in our hands, not because it did not arrest the 
bleeding, but on account of the filthy condition in which it 



232 DISEASES OF THE RECTUM AND ANUS. 

Leaves the wound. In our experience water, 7iot or cold, in 
conjunction with compression, has been satisfactory in every 
respect. When the hemorrhage is profuse, time should not be 
wasted on injections and powders. The rectum should be ex- 
posed by means of a speculum and the bleeding vessel searched 
for until it is found and ligated or seared over with the 
Paquelin cautery. If the operator be not so fortunate as to 
have one of these convenient and valuable instruments, a poker 
or a curling-iron may be heated to a red heat and used as a 
substitute. In case the vessel is situated so high that a ligature 
cannot be applied, it should be seized with a pair of artery- 
forceps and thoroughly twisted, and the forceps left on if neces- 
sary ; for in cases of profuse hemorrhage of the rectum the 
patient's life not infrequently hangs upon the thoroughness of 
the work. In case the bleeding-point cannot be located, we 
must then resort to packing the rectum, which must be well 
done ; for there is nothing more deceptive than to shove a lot 
of gauze or other packing loosely into the rectum with the idea 
that it will hit the right spot and arrest the bleeding. The 
pressure must be made firmly and equally on every side. Mr. 
Allingham packs the rectum after the following manner : He 
takes a cone-shaped sponge and places a strong ligature through 
it near the apex. It is then brought back again, so that the 
apex is held in a loop ; the sponge is dampened and dusted 
over with some astringent — preferably iron — and squeezed dry ; 
after which, guided by the index finger, it is introduced into the 
rectum, apex first, and carried up Hve inches (12.7 centimetres), 
leaving the ends of the ligature outside the anus. The rectum 
below the sponge is packed with cotton, dusted over with as- 
tringent powder. When this is completed he seizes the ligature 
and pulls the sponge downward with one hand and pushes the 
cotton up with the other. In this way the sponge is made to 
spread out and the cotton compressed tightly at the same time. 
And. if this be done carefully, he asserts that it is impossible 
for bleeding to occur either internally or externally. We have 



HEMORRHAGE FROM THE RECTUM. 



233 



resorted to this procedure in one case only, and it proved quite 
effective. Another admirable method of arresting the bleeding 
is the India-rubber tampon of Mr. Benton, of England, improved 
by Mr. Edwards as shown in the latter's work. (See Fig. 76.) 
The majority of operations on the rectum are performed 




Fig. 76.— Benton's India-Rubber Tampon. (Modified by Edwards.) 

on the lower inch and a half (3.8 centimetres) of it. When 
bleeding occurs in this locality it can be speedily arrested by 
inserting into the rectum a firm piece of rubber tubing, three 
inches (7.6 centimetres) long and three-fourths of an inch (1.9 
centimetres) in diameter, around which has been wrapped 
several layers of gauze. It can be kept in place by placing a 
safety-pin through the outer end and into a T-bandage. It 




Fig. 77.— Drainage-Tube Wrapped with Gauze. 

makes a desirable compress and at the same time allows the 
escape of wind and discharges, and warns us in case the bleed- 
ing has not been arrested. (See Eig. 77.) Hollow vulcanite 
tubes (see Fig. 78), kept at most any instrument-dealer's store, 
act in the same way. The main factor in arresting hemorrhage 
after any operation about the rectum, where the cautery or 



234 DISEASES OF THE RECTUM AND ANUS. 

Ligature cannot be used, is to make firm and constant pressure 
over the bleeding-points. 

We once more call attention to the fact that when it 
becomes necessary to pack the rectum it should be done 




Fig. 78. — Hollow Vulcanite Drainage-Tube. 



thoroughly, so that not a single point of the rectum will be 
exempt from the pressure ; when this has been accomplished, 
we can retire with the assurance that our patient is perfectly 
safe and that all bleeding has been arrested. 



CHAPTER XXI. 

PRURITUS ANI (ITCHING PILES). 

Itching of the anus seems to us to be the most intractable 
of any of the diseases of the rectum and anus which we have 
been called upon to treat. It is very distressing and dishearten- 
ing* when present in an aggravated form. Patients frequently 
remark that the itching is milch more difficult to endure than 
acute pain, and that their lives are rendered almost unbearable 
by it. The term pruritus ani has been applied to all cutaneous 
affections of an itching character occurring about the anus. In 
many cases there will be no visible pathological change, and no 
cause can be found to account for the itching ; the pruritus, 
however, is usually a symptom of some other disease. It occurs 
more frequently in the male than in the female, and at middle 
life. It is usually more or less constant, but becomes more intense 
after the patient becomes warm in bed at night. The itching is 
not always limited to the margin of the anus, but may be found 
radiating from it in all directions, extending up the scrotum, 
down the limbs, and over the coccyx and the sacrum in very 
bad cases, while numerous cracks and fissures are to be seen as 
results of the scratching. Rubbing the part to relieve the itch- 
ing gives only temporary relief, yet few are able to withstand 
the temptation, though they know from experience that by so 
doing they only make their suffering the more difficult to bear 
on the morrow. The friction excoriates the skin, and in cases 
of long standing the latter becomes dry and glistens like parch- 
ment. After a time the pigment is destroyed and the skin is 
white. 

Etiology. 

In some cases the cause can be readily ascertained, and, if 
removed, a cure rapidly follows ; in others no cause can be 
found to explain its presence. This has led to much discussion. 

(235) 



236 DISEASES OF THE RECTUM AND ANUS. 

Some claim that the pruritus is due to a local and others that it 
is due to a constitutional disturbance ; while others believe it to 
be a result of habit or some neurotic condition. In a given 
number of cases, no doubt, all of the named factors play an 
important part. We have, in many instances, seen the itching 
disappear when we had destroyed thread-worms which were 
found in the anal folds. We have seen it produced as a result 
of impacted feces, hemorrhoids, ulceration, prolapsus, fistula, 
and fissures ; in fact, anything which encourages a discharge 
from the rectum may induce it. Pediculi and other parasites 
are not infrequent causes ; and the same might be said of 
erythema, herpes, or of any variety of eczema, either acute or 
chronic. Errors in diet — especially the overindulgence in 
alcoholic stimulants or highly-seasoned foods — and irregular 
habits will likewise produce this condition or aggravate it when 
it already exists. 

Symptoms. 

The most prominent symptom is the unbearable itcJiing, 
which is made more intense by warmth and contact of the sur- 
faces of the buttocks. We have seen many cases where patients 
were unable to obtain rest for several nights at a time ; and in 
some cases, where they dropped off to sleep, they would scratch 
themselves while unconscious, thus excoriating the anal margin, 
which renders suffering the more intense on the following day. 
Wo have had a number of patients tell us that, if we did not 
relieve them, they would commit suicide. Only the other day 
a physician made that assertion, for life, in his condition, was 
simply unbearable. From what has been said, we trust that 
we have made the gravity of this condition apparent, though it 
is so frequently made light of. 

Treatment. 
The treatment consists first in the removal of the cause 
when it can be determined ; but when there is no ascertainable 
local cause and the patient is debilitated or of a strumous dia- 



PRURITUS ANI (ITCHING PILES). 237 

thesis, much benefit may be derived from Fowler's solution of 
arsenic in full doses, codliver-oil, iron, quinine, or from any of the 
numerous remedies employed to build up the system in general. 
If there is reason to believe it due to excesses in eating and 
drinking, the latter should be prohibited and a light diet or- 
dered. When it is due to thread-worms, injections of salt- or 
lime- water will ordinarily destroy them ; in very obstinate cases, 
however, santonine and other anthelmintics will have to be 
used. When due to eczema and the skin is dry and scaly, we 
observe the most benefit from the use of tar preparations, the 
best of which is the soap-liniment. Often much relief is afforded 
by bathing the parts with a solution of alcohol or tar-water. 
When due to eczema of the moist variety, soothing applications 
are preferable, and a good one is boric acid dusted over the 
moist surface. The two raw surfaces should then be separated 
by gauze or other soft dressing to prevent irritation of the 
parts and a spread of the disease. In eczema marginatum, dilute 
sulphurous acid, applied after the parts have been cleansed by 
warm soap-suds, will prove very effective as a cure, and will give 
almost immediate relief. In many cases, unattended by any ob- 
servable local pathological changes, the itching is frequently so 
annoying that palliative remedies are urgently demanded ; these 
are best prescribed either in the form of ointment or lotion, and 
are composed of one or more of the following astringent med- 
icines : Acetate of lead, opium, zinc preparations, chloroform, 
mercury, carbolic acid, salicylic acid, biborate of soda, etc. We 
have derived immediate relief from brushing the diseased parts 
with a solution of silver nitrate (twenty grains to the ounce) or 
ChurchilPs tincture of iodine twice or thrice weekly, both of 
which cause some immediate pain, but the relief afforded twenty- 
four hours later will be sufficient to repay patients for all the 
pain they have suffered from the application. In St. Mark's 
Hospital, London, as a rule, they use the following formula, 
which is to be made fresh and applied daily with a camel's hair 
brush or with cotton : — 



k 238 DISEASES OF THE RECTUM AND ANUS. 

R Liq. plmnbi eubacetat. (fort.). • • • 3j ( 4 c. cm.); 

Lactis, 3vij(28 c.cm.) ; 

Misce. 

Iii cases of eczema, Dr. Bulkley, of New York, recommends 
the following-, after cleansing the parts thoroughly with Castile 
soap : — 

R Liq. carbonis detergens (Wright's), . . ^j ( 30 c.cm.); 

Glycerini, 5J ( 30 c.cm.); 

Zinci oxidi, ^ss ( 15 grammes) ; 

Pulvis calamine prep., 3ss ( 2 c.cm.); 

Aqure, £vj (180 c.cm.). 

M. Sig. : Apply with brush and allow it to dry daily. 

This is his favorite prescription. 

All of the various tar-ointments will be found serviceable. 
One of the best is composed of 

R Ungt. picis, -Jiij (12 grammes) ; 

Ungt. belladonna?, . . . . . . 3ij ( 8 grammes) ; 

Tinct. aconiti, 3ss ( 2 c.cm) ; 

Ungt. aquse rosce, 3iij (12 grammes). 

Space forbids my giving the hundred and one prescriptions 
which have been recommended to cure this annoying condition. 
In many cases it will be found necessary to change from one 
remedy to another until one is found which suits the case in 
hand. This should lead us to be very careful in our prognosis, 
and not commit ourselves as to any specified time that it will 
require to effect a cure in any given case. 

In nervous cases troubled with insomnia it will be neces- 
sary to give something that will enable the patient to sleep. 
We much prefer chloral or the bromides to an opiate, for the 
latter makes the itching all the more intense on the following 
day, though it docs enable patients to get some immediate rest. 
Allingham, of London, has invented a very ingenious little 
instrument to relieve the itching during the night. It consists 
of a bone or ivory plug, shaped like the nipple of an infant's 
feeding-bottle. When it is inserted into the anus, it is retained. 
It is about two inches (5 centimetres) in length and as thick as 



PRURITUS ANI (ITCHING PILES). 239 

the end of the index finger. He claims that it prevents noc- 
turnal itching, by exercising pressure upon the venous plexuses 
and terminal nerve-filaments close to the anus. It gives us 
great pleasure to recommend this little device, for we have tried 
it a number of times and have always found that it relieved or 
palliated the itching. 

Surgical Treatment. — The surgical treatment consists, first, 
in the removal or the cure of any local disease present that 
would be likely to intensify the itching, such as ulcers, hemor- 
rhoids, fissures, polypi, eczema, etc. Thorough divulsion of 
the sphincter and a few applications of silver to any fissures 
and ulcers that might be present will nearly always cure them 
and thereby relieve the itching. Simple divulsion of the 
sphincters, where no local cause could be detected, has given 
relief in not a few cases ; we are unable to state why at present. 
In one or two cases in which the skin was lacerated for a con- 
siderable distance about the anus, and where it failed to get 
well after the sphincter had been divulsed and the usual rem- 
edies tried, an anesthetic was administered and the diseased 
parts were thoroughly curetted and then cauterized with a 
Paquelin cautery-point. The raw surface left was treated like 
an ordinary burn, and it healed kindly in a short time and the 
itching ceased altogether, proving that the cause of the pruritus 
was, without doubt, within the skin and of germicidal origin. 
Many of these sufferers will wander from one physician to an- 
other until they are in a most pitiable condition and almost 
beyond human aid. This is largely their own fault, for many 
become discouraged and seek a change ere the physician in 
charge has had a chance to do the patient and himself justice. 
Even in the most deplorable cases, with due care, the aid of 
surgery, lotions and ointments judiciously applied, their lives 
may be rendered bearable and a cure effected, provided they 
surrender themselves entirely to our care. In conclusion, we 
wish to say that, as a rule, the more radical the treatment, the 
quicker the patient will get well. 



240 DISEASES OF THE RECTUM AND ANUS. 

ILLUSTRATIVE CASE. 

Case XXX. — Pruritus Ani (Aggravated Case). 

The case in point was that of a Frenchman of exceedingly nervous 
temperament and an inveterate smoker. The itching commenced fifteen 
years ago, but of late had become so intense that he was unable to sleep 
at night, and he suffered much during the day from itching and pain 
where the skin had been lacerated. Like all who suffer from this com- 
plaint, he had tried numerous prescriptions and pile-ointments recom- 
mended to cure it, without any benefit whatever. He said that, if he did 
not get relief soon, he would commit suicide, for life was simply unbear- 
able. On examination I found the skin in and around the anus thick 
and parchment-like ; here and there large fissures and cracks, which were 
produced by the constant scratching. Internal examination revealed the 
presence of a large, unhealthy ulcer with raised edges, and, from all 
indications, it had been there for months, if not years. I ascribed the 
outer condition to the foul discharge from the ulcer, and determined to 
cure the same before trying to relieve the itching. Accordingly, the 
ulcer was curetted and incised in two places through several layers of 
the sphincter, to insure rest. It was then brushed over with pure nitric 
acid, and he was placed in bed. He progressed nicely, and on the third 
day the rectum was washed out with carbolized water and a solution of 
silver nitrate, twenty grains to the ounce, was applied to the ulcer. In 
addition to this, I applied Churchill's tincture of iodine over the itching 
area after brushing it over with a 6-per-cent. solution of cocaine. From 
this time on the rectum was cleansed daily, and silver was applied both 
to the ulcer and to the itching area twice a week for three weeks, when 
the ulcer completely healed. The applications were continued to the 
outer part one week longer; he was then discharged, the itching being 
entirely relieved. I instructed him to keep his bowels in good condition 
and to bathe the parts every night in cold water. 



CHAPTER XXII. 
DIARRHEA AND DISCHARGES. 

In the chapter on the symptomatology of rectal disease 
we mentioned diarrhea and discharges as being symptoms of 
certain diseases. It is our purpose, in this chapter, to consider 
diarrhea and discharges in detail, that a better understanding 
may be had of them and their diagnostic importance in so far 
as they relate to the study of rectal diseases. During the past 
few years we have had many patients come to us suffering from 
some serious rectal disease. They had been treated for weeks 
and months by internal medication for chronic diarrhea, when 
the frequent stools were excited by a local disease situated in 
the terminal portion of the colon. That in these cases the 
diarrhea was due to local irritation alone was proven by the 
fact that all internal medication was discarded when the seat of 
the disease had been located and a local treatment substituted. 
Invariably when the local disease was cured there would be a 
cessation of the diarrhea. A few weeks ago a lady came to us 
for treatment and gave the following history : She had been 
treated for more than three years for chronic diarrhea, supposed 
to be the result of some derangement of the liver ; she had from 
fifteen to twenty liquid stools in twenty-four hours ; the stools 
were now and then mixed with pus and mucus. The actions 
were preceded and followed by more or less pain, straining, and 
spasmodic contraction of the anal sphincters. On inquiry she 
informed us that her rectum had never been examined and she 
did not think it necessary to have it examined, for diarrhea was 
the only thing that troubled her. We insisted upon the neces- 
sity of an examination ; she finally consented, and we found a 
large ulcer one inch (2.54 centimetres) above the anus, on the 
posterior wall of the rectum ; this ulcer was evidently the source 
of irritation. The sphincters were immediately divulsed, the 

16 (241) 



242 DISEASES OF THE RECTUM AND ANUS. 

ulcer curetted, and a strong solution of silver nitrate applied to 
its base. For two weeks thereafter stimulating applications 
were made to it. By this time all the diarrheal symptoms had 
disappeared and she was discharged from the hospital cured. 
We have treated a few cases wherein the diarrhea preceded and 
caused the local rectal irritation as a result of the frequent irri- 
tating discharges produced by some disease situated higher up 
in the colon. In such a case as the one mentioned, if the orig- 
inal irritation is removed or corrected and the rectal disease 
remains uncared for, it becomes an independent source of irri- 
tation, excites peristalsis and frequent stools, thus producing the 
same condition that formerly gave it birth. Any one of the 
following diseases, when located either in the rectum or sigmoid, 
will be accompanied by symptoms that might be mistaken for 
a simple " chronic diarrhea." For this reason we will deal with 
them separately, that we may more fully point out their diag- 
nostic significance : — 

1. Chronic catarrh. 5. Prolapsus. 

2. Stricture. 6. Polypi. 

3. Ulceration. 7. Fecal impaction. 

4. Malignant disease. 8. Villous tumors. 

Chronic Catarrh. — Inflammation of the rectum and of the 
sigmoid is frequently mistaken for diarrhea, and they occur 
often, because: 1. In the first place, all irritating foods that 
have been hurried through other portions of the digestive tract 
are longer delayed in the lower portion of the colon. 2. The 
feces become firm and nodular and are jostled from side to side, 
during peristalsis, against the sensitive mucous membrane. 3. 
The feces undergo certain putrefactive changes while still in 
the colon, thus exposing any unsound portion of the mucous 
membrane to the septic organisms contained therein. 

Stricture. — A stricture, from any cause, that is sufficiently 
marked to produce a mechanical obstruction may cause diar- 
rheal symptoms for two reasons. First, when a stricture is of 
long standing there will invariably be more or less ulceration at 



DIARRHEA AND DISCHARGES. 243 

or above the constriction. This exposes the terminal nerve- 
filaments to any irritating substances. As a result undue 
peristalsis is excited, causing frequent stools. In the second 
place, the liquid feces are readily discharged through the con- 
striction, while firm and well-formed feces are unable to pass 
and accumulate just above it, become hard, irregular in shape, 
and smeared over with a glairy mucus. At frequent intervals 
this mass presses down upon the stricture, producing a sensa- 
tion similar to that felt before stool ; the sufferer goes to the 
closet and endeavors, by continued straining, to empty the bowel, 
but is unable to do so. The mass then acts as a valve ; it rises 
and falls, each time exciting renewed peristalsis, which extends 
upward along the entire intestinal canal, causing the immediate 
discharge around the mass of any fluids contained therein. As 
a result of this abnormal condition, these sufferers spend most 
of their time in the closet straining, and the bowel is being con- 
stantly squeezed dry of everything excepting the impacted mass 
One of these patients once remarked to us that everything she ate 
seemed to be converted immediately into liquid and passed right 
through her. 

Ulceration. — In point of frequency as a cause of diarrhea 
ulceration comes next to catarrh. All who do very much rectal 
work must have observed the frequency of diarrhea as a symp- 
tom of ulceration of the rectum and the sigmoid. Whenever 
the ulcer becomes irritable and very sensitive, any little particle 
of fecal matter lodged within it or the passage of any irritating 
discharge will prove sufficient to excite frequent and prolonged 
peristalsis, resulting in much straining and frequent stools. 
This w r e have seen demonstrated many times. 

Malignant Disease. — Diarrhea constitutes the most trouble- 
some symptom with which we have to deal in the treatment of 
malignant disease of the lower portion of the colon. The 
straining and the pains which sufferers from this disease have 
to endure are pitiable to behold, especially in the later stages 
of the disease. It has been only a few weeks since a ladv was 



244 DISEASES OF THE RECTUM AND ANUS. 

brought to us for treatment. She was suffering from a cancer- 
ous stricture of the rectum with the above symptoms. She had 
been treated for diarrhea for more than eight months, and a 
rectal disease had never been suspected. 

Prolapsus {including Invagination). — Cases of prolapsus 
and invagination of the rectum and the sigmoid have been 
mistaken and treated for chronic diarrhea, on account of the 
frequent discharges of large quantities of mucus. Mucous dis- 
charges are always present when either of these conditions is 
found. 

Polypi. — Polypi, when located either in the rectum or in 
the sigmoid, act as a source of irritation and excite an abnormal 
secretion of mucus, which is discharged at frequent intervals 
and may be mistaken for chronic diarrhea from other causes. 

Impaction of feces. — It is a well-known fact that diarrhea 
is sometimes a symptom of fecal impaction. Well-formed feces 
cannot pass the impacted mass, which, acting as an irritant, 
excites peristalsis and causes only the liquid portions of the 
feces to be discharged, at frequent intervals, around the 
impacted mass. 

Villous Tumors. — The leading symptom of a villous tumor 
is frequent discharge of large quantities of mucus which 
resembles very much the white of an egg. 

Pathological Anatomy. 
The pathological anatomy in cases of chronic diarrhea 
varies in appearance very much, depending upon the disease 
which produces it as well as the length of time it has existed. 
When diarrheal symptoms are the result of prolapsus, polypi, 
villous tumors, colitis, proctitis, or impaction, the mucous mem- 
brane will appear congested and will be smeared over with a 
thick, glairy mucus, pus, or both. If these are not corrected 
the membrane soon loses its smooth, velvety appearance ; be- 
comes much thickened, indurated, and firmly attached to the 
submucous tissues, sometimes forming a long, tubular stricture. 



DIARRHEA AND DISCHARGES. 245 

When due to ulceration, stricture, and malignant disease, the 
mucous membrane, in the earlier stages of the disease, presents 
an appearance very much like that referred to above ; but when 
the ulceration begins to extend, it soon loses that smooth feel 
and appears ragged and irregular to the touch. When a 
stricture has formed, no matter whether it be malignant or not, 
ulceration will almost invariably be present at the point of con- 
striction as well as above and below it. In many cases there 
will be a periproctitis, which may terminate in an abscess and 
fistula. The entire rectal wall will be very thick, hard, and 
firmly attached to the neighboring tissues and organs. The 
finger, introduced into the bowel, will come in contact with 
many irregularly shaped nodules, cavities, or cicatricial bands ; 
and when passed within the constriction, a sensation is felt 
similar to that produced by a strong rubber band placed around 
the end of the finger. 

Symptomatology. 

Pain, tenesmus, and frequent stools are undoubtedly the 
most annoying of the many and varied symptoms of which 
these sufferers complain. In one case they will be mild, in 
another severe, depending both upon the disease and the extent 
to which it has progressed. When the symptoms are due to 
polypi, villous tumors, prolapsus, impaction of feces, chronic 
colitis, or proctitis, the symptoms will be very much alike, — that 
is to say, in all probability there will be from six to ten stools 
daily, accompanied by a smarting, burning pain, tenesmus, and 
eversion of the mucous membrane, which will be congested. 
When a prolapsus, a polypus, or a villous tumor is present, in 
addition to the above symptoms, the patient will complain of 
something protruding from the anus. 

Character of the Stools. — They are always liquid or semi- 
solid. The majority of them will be made up entirely of mucus, 
which will be mixed now and then with pus and blood when 
ulceration has commenced. The remainder of the stools will 



246 DISEASES OF THE RECTUM AND ANUS. 

consist of liquid and semisolid feces. Sometimes patients com- 
plain of pain and tenesmus over some portion of the intestines 
or colon, to be followed on the morrow by frequent discharges 
of mucus and shreds and sometimes almost perfect casts of the 
bowels, which at first appear to be the mucous membrane itself, 
but when pulled apart prove to be thick exudations that have 
formed on the membrane, resembling the false membrane seen 
in diphtheria. The cause of this variety of inflammation is 
very obscure at the present time. It is thought to be of nervous 
origin and we have been in the habit of diagnosing such cases 
as membranous enteritis. When the mucous membrane is irri- 
tated from any of the diseases mentioned, the sphincters ani will 
alternately contract and relax, causing the patient much annoy- 
ance ; and, when the exciting cause remains for any great length 
of time, the sphincters become tired out and remain passive, 
necessitating the wearing of a napkin constantly to prevent the 
escape of the feces. 

In the earlier stages of ulceration, stricture, and malignant 
disease, one or all of the symptoms just described may be 
present ; they become aggravated as the disease- progresses. 
In addition to them, there will be a variety of reflex disturb- 
ances of the neighboring organs that are liable to be mistaken 
for ovarian neuralgia, diseases of the uterus, prostate, or other 
pelvic diseases. There will be pains in the back, abdomen, 
and down the limbs ; but the most annoying symptom of 
them all is the almost constant straining and never ceasing 
desire to empty the bowel, which many times is a physical im- 
possibility. When a stricture is present, no matter whether it 
be malignant or not, the liquid feces are discharged through it 
at short intervals, while the solid portion accumulates above it 
and acts as a foreign body, producing the sensation felt just 
before stool. As a result these sufferers spend much of their 
time in the closet, straining and trying to empty the bowel, — a 
thing impossible to do on account of the mechanical obstruction. 
They arc forced to leave the closet with the feeling that some- 



DIARRHEA AND DISCHARGES. 247 

thing that ought to pass away still remains in the bowel. In 
all such cases the sphincters become passive and the annoyance 
of incontinence is added to the suffering. It is hardly necessary 
to call attention to the fact that these patients look worn out, 
have a sallow complexion, hollow eyes, are extremely nervous, 
and that many of them are in the habit of taking morphine, 
opium, chloral, or the bromides that they may get relief from 
pain and tenesmus. 

Diagnosis. 

It is easy to make a correct diagnosis of any of the diseases 
under discussion if one first get a history of the case and then 
make a thorough digital and visual examination of the rectum 
and as much of the colon as possible. Whenever there is any 
doubt as to the real conditions present, the patient should be 
placed on the table in a good light, and the examination com- 
pleted under chloroform. In chronic catarrh the mucous mem- 
brane will be congested, thickened, immovable, and smeared over 
with an abundance of thick, glairy, ropy mucus. A sweep of the 
finger around the rectal wall will readily detect the presence of 
polypi, for they are always attached by a long, narrow pedicle. 
A prolapsus will be recognized by the everted mucous mem- 
brane, the globular form of the tumor, the slit in its centre, and 
the fact that not only one side, but the entire circumference of 
the bowel is involved. When ulceration is present the mucous 
membrane will feel irregular and ragged to the touch. When a 
speculum is used, the ulcers, when located within four or five 
inches (10 or 12.7 centimetres) of the anus, come into plain 
view. Malignant disease and stricture can be recognized by 
the diminution in the calibre of the bowel, as a result of cica- 
tricial bands, or from hard nodular tumors, with ulceration at 
and above the point of constriction. When extensive ulceration 
is present the stools will vary in frequency, from four to fifteen 
a day, and will be almost entirely liquid, for the reason that the 
food is not retained long enough within the intestinal tract to 



248 DISEASES OF THE RECTUM AND ANUS. 

become firm. There will be frequent discharges of mucus 
mixed with pus and tinged with blood. Now and then, when 
the ulceration has encroached upon a blood-vessel, the entire 
motion will be made up of clotted blood. In malignant disease 
and stricture the discharges resemble those of extensive ulcer- 
ation, but added to them are small detachments of broken-down 
tissue. In the later stages there will be more or less blood in 
every stool ; the blood becomes mixed with mucus and pus, 
giving the discharge an appearance not unlike cold coffee- 
grounds. The discharges become more frequent as the tissues 
break down. 

Prognosis. 
The prognosis of chronic catarrh, prolapsus, villous tumors, 
and polypi is usually good, and a cure may be obtained in a 
short time. In benign stricture and in ideeration it is good in 
so far as a fatal termination is concerned. There are many 
cases, however, that require a long treatment ; and we cannot 
promise some patients anything beyond a fairly-comfortable ex- 
istence. In malignant disease the prognosis is exceedingly un- 
favorable. Unless the disease is recognized and removed almost 
at its inception, death will ensue in a few months. We can, 
however, prolong life from six months to three years, and make 
such patients comparatively comfortable while they do live, if 
they will submit to colotomy. 

Treatment. 
The first step in the successful treatment of the conditions 
under discussion is to search out the cause and remove it, else 
all remedies given to arrest the frequent stools and discharges 
will be of no permanent benefit. We shall not attempt in this 
chapter to enter into the minute details of the treatment of the 
various pathological conditions that might cause frequent stools 
or discharges of various kinds. We shall mention only the 
most salient features, referring those who desire further informa- 
tion to other chapters wherein treatment of these diseases is 



DIARRHEA AND DISCHARGES. 249 

discussed at length. In all treatments the diet should be re- 
stricted to non-irritating, easily-digestible foods, such as soup, 
soft-boiled eggs, pure beef-juice, broiled steak, plenty of milk, 
etc. Regular hours for eating, sleeping, exercising, and attend- 
ing to the calls of nature must be insisted upon, for irregularities 
in living are largely responsible for many of these diseases. 
When there is any constipation it should be corrected by mass- 
age of the intestines, assisted by moderate quantities of some 
mild cathartic mineral waters or a tonic pill composed of aloin, 
strychnine, and belladonna, given three times daily. Strong 
purgatives are* contra-indicated ; their effect is temporary, and 
frequently they only increase the irritation already present. 
The treatment proper should be both 

1. Palliative. 2. Operative. 

Chronic Catarrh. — There are two essential features in the 
treatment of this condition : first, absolute rest in bed in the 
recumbent position ; second, the bowels should be kept clear of 
all irritating ingesta. In addition to these, the rectum and 
colon must be flushed daily with large quantities of boiled, 
filtered water and antiseptic and astringent solutions. We have 
been in the habit of injecting, through a colonic tube, a quart 
of water containing thirty grains of the nitrate of silver twice a 
week. In tbe meantime some good solution, such as weak 
alum-water, — say, two teaspoonfuls to half a gallon of water, — 
is injected every night. A favorite injection is composed of 
boiled linseed-oil, two ounces ; subnitrate of bismuth, one 
drachm ; and the balsam of Peru, two drachms. Mathews, of 
Louisville, prefers the following : — 

R Sweet almond-oil, Oj (473.11 c. cm.) ; 

Subnitrate of bismuth, . . . . ^iij ( 93.31 grammes) ; 

Iodoform, 3j ( 3.88 grammes). 

Sig. : Shake well and inject one ounce twice a week. 

We have recently tried this prescription in two very 
aggravated cases and were well pleased with the results. A 



250 DISEASES OF THE RECTUM AND ANUS. 

fountain-syringe will do to flush the rectum, but we much 
prefer a Davidson or large, hard-rubber piston-syringe, when the 
medicine is to be thrown into tlie colon, for two reasons : In the 
first place, when attached to the tube, if the latter get lost in a 
fold of the mucous membrane, the water can be thrown against 
it with such force as to raise it, and the tube will then pass 
upward into the sigmoid and the colon ; in the second place, 
the exact amount of medication that we desire to use can be 
thrown into the bowel. On the other hand, when the fountain- 
syringe is used, a small quantity is liable to be lost in the long 
tubing. 

Stricture of the rectum requires both palliative and opera- 
tive treatment. The object in the first is to alleviate the pain 
that the patient may obtain rest, and is best done by keeping 
the bowel clean by flushing it with antiseptic solutions, to be 
followed up by the use of soothing lotions, applications, and 
ointments. The operative procedures resorted to for the relief 
of strictures are three in number (see chapter on stricture) : — 

1. Colotomy. 3. Dilatation : 

2. Posterior proctotomy. (a) Gradual or (b) forcible. 

We might add that in cancer the indications for treatment 
are almost identical with those of stricture. 

Polypi. — The treatment of polypi is very simple. They 
are seized witli a pair of catch-tooth forceps, pulled down, 
ligated, and that portion external to the ligature excised. 

Prolapsus in mild cases should be treated by astringent 
injections, and nitric acid applied to the redundant tissue. 
When an operation is indicated there are a number to choose 
from, but the most satisfactory is to draw a Paquelin cautery- 
point over the redundant mucous membrane a number of times 
from above downward ; if it is a very bad case the point should 
be pressed deeply into the sphincter muscle in two or three 
places. Some prefer excision of the protruding portion of the 
gut, and still others recommend certain plastic operations. 



DIARRHEA AND DISCHARGES. 251 

Ulceration. — Simple ulceration of the rectum or the sig- 
moid will usually heal when kept clean and stimulated by the 
application of nitrate of silver (gr. xv to the ounce), balsam of 
Peru, calomel, and the stearate of zinc with iodoform, menthol, 
or ichthyol. When the ulceration is chronic, it will be necessary 
to either divulse or incise the sphincter and curette the ulcer. 
The after-treatment consists in keeping the rectum clean and 
applying the stimulating medicines just named ; in all prob- 
ability the ulceration will be perfectly healed in two weeks. 

Villous Tumors. — Villous tumors are best removed by 
transfixing their bases with double ligatures. This ligature is 
to be cut and each side tied separately. 

Fecal Impaction. — Fecal impaction can be relieved by 
abundant and frequent injection of hot water, oil of turpentine, 
etc., in conjunction with frequent massage of the fecal tumor. 

ILLUSTRATIVE CASES. 
Case XXXI. — Chronic Diarrhea Caused by Ulceration. 

I present this case from the fact that it is of interest to both the 
surgeon and the general practitioner. The patient was a married lady 
30 years old. She informed me that she had suffered from diarrhea for 
five 3 T ears, often going to the closet eight or ten times a day. She had 
experimented with various medicines, she had been prescribed for by 
prominent physicians, and she had taken patent nostrums, but all to no 
purpose. The Chinese doctor had been consulted ; he failed to cure her ; 
she then tried osteopathy with a like result. Becoming discouraged, she 
went to her family physician ; he referred her to me for treatment. An 
examination revealed the presence of several unhealthy ulcers extending 
from the upper margin of the external sphincter below to the upper 
portion of the internal. They varied in size from that of a green pea to 
a quarter of a dollar, the largest one being on the posterior surface. After 
the patient was anesthetized and the sphincter clivnlsed, I curetted the 
ulcers and incised the large one, which was situated directfv over the 
muscle, to prevent its contracting. The ulcernted area was then brushed 
over with silver nitrate. On the third da} r after the operation she had an 
action from her bowels. The rectum was then irrigated and the silver 
applied to the ulcer again. The same procedure was carried out every 
three da} r s for a month, when the ulcers were entirely healed. During 



'252 DISEASES OF THE RECTUM AND ANUS. 

this t ime she had not the slightest tendency to diarrhea. At the end of 
six weeks I lost sight of her and did not see her again for twelve months, 
when one day she called at my office and informed me that she had 
entirely recovered. 

Case XXXII. — Chronic Diarrhea Caused by Rectal Polypi. 

Mr. W. B., a photographer, came to me suffering from a chronic 
diarrhea of four years' standing, with the following symptoms: He had 
from four to ten actions daily, which were accompanied by a great deal 
of pain and straining. The stools were always liquid and consisted of 
mucus. The bowel felt as if some foreign bod}' were within the rectum, ex- 
citing almost constant irritation and a desire to go to stool. He had under- 
gone treatment from a number of physicians, who diagnosed his case as 
one of simple chronic diarrhea and prescribed accordingly. On account 
of the large quantities of mucus discharged, I suspected some local dis- 
ease of the colon or the rectum, and proceeded to make a digital exam- 
ination. Immediately upon the introduction of the finger, I detected a 
large, soft tumor the size of an English walnut. Further examination 
revealed the presence of another equal in size. The finger could be 
passed around them, and their attachment to the rectal wall was located 
with little difficulty. 

Treatment. — He was chloroformed, placed in lithotomy position, 
and the rectum irrigated. The tumors were in turn seized, pulled down- 
ward, and the author's clamp was tightty adjusted to the pedicle at its 
junction with the mucous membrane. That portion of the polypus ex- 
ternal to the clamp was then excised (as in the operation for hemorroids) 
and the stump carefully cauterized with a Paquelin cautery. The patient 
was placed in bed, and the nurse instructed to keep him quiet for thirt}'- 
six hours. On the third day his bowels acted, and he was allowed to 
walk around some. At the end of one week he returned to the gallery, 
and from then to the present time, two years after the opration, he has 
not been troubled with diarrhea. I recite this case for the reason that it 
proves beyond a doubt that the frequent stools were the result of the 
irritation excited by the presence of the polypi, and not from any 
abnormal condition of the stomach or small intestine. 



CHAPTER XXIII. 

CONSTIPATION. 

• It is doubtful if there is any other ailment that we are 
subject to which is more prevalent, causes more annoyance, or 
taxes the patience of both physician and patient more than per- 
sistent constipation. It is not always an easy thing to tell just 
where health leaves off and constipation begins. Physiology 
teaches us that we ought to have at least one free action in 
every twenty-four hours; yet it is an every-day occurrence to see 
those who do not have an action more than once every two or 
three days, and still others who may have two actions daily, 
and so far as appearances go one is just as healthy as the other. 
Constipation is one of the most frequent symptoms of rectal 
disease, and at the same time one of the most common causes 
of the same. In fact, it may be a symptom of some other dis- 
ease or an independent disease of itself. There are so many 
causes of constipation that we shall not attempt to record them 
all, but will mention the more common ones under the following 
headings : — 

1. Mechanical obstruction. 3. Deficiency of the secretions. 

2. Defective peristaltic action. 4. Sundiy causes. 

Mechanical Obstruction. 
Under the first heading are included all those causes 
whereby the feces are prevented from having a free passage 
along the intestinal tract, — as stricture, congenital or otherwise ; 
polypi, tumors within or without the bowel, intussusception, 
enlarged prostate, prolapsed uterus, etc. 

Defective Peristaltic Action. 
There are many things that play their respective parts 
in causing a diminished peristaltic action ; irregular habits in 

(253) 



!254 DISEASES OF THE RECTUM AND ANUS. 

living, however, heads the list, and the manner in which it does 
so becomes at once apparent when we study the act of defeca- 
tion. Modern physiology teaches that the feces collect in the 
lower portion of the sigmoid and remain there until shortly 
before stool, when peristalsis commences and they are moved 
downward into the rectum, and the desire to go to stool is felt. 
If this warning of the approach of the feces is appreciated and 
the contents of the rectum promptly expelled, all is well ; on 
the other hand, when this hint is ignored, reverse peristalsis 
returns the feces to the sigmoid, where they remain until they 
are again propelled into the rectum, causing the sensation just 
described. If this, like previous sensations, is ignored day after 
day, the mucous membrane soon loses its sensitiveness and the 
muscular coat its tonicity, and, as a result, large quantities of 
lecal matter may accumulate in the sigmoid and the rectum 
without causing the least desire to go to stool. Irregular time 
for eating and improper diet are prone to diminish peristaltic 
action ; for it is a well-known fact that foods that contain very 
little liquids and those that leave little residue are liable to 
accumulate in the bowel and some time press upon the nerves 
sufficiently to produce a paresis of the same. 

Deficiency of the Secretions. 

Many of the causes that produce a diminished peristaltic 
action are equally prone to lessen the normal secretions of the 
bowel. Again, the intestinal secretions are diminished in certain 
hepatic diseases where there is a deficiency in the amount of 
bile emptied into the bowel, also when there is inactivity of the 
intestinal glands from any cause. 

Sundry Causes. 

Under this heading are included those causes that are the 
result of disturbances that are more general in character, such 
as diabetes, melancholia, insanity, old age, and many others, 
including those that are purely of local origin in the terminal 



CONSTIPATION. 255 

portion of the colon and the rectum. We will mention these in 
the order of their frequency as causes of constipation : — 

1. Anal fissure. 3. Stricture (benign or malignant). 

2. Ulceration. 4. Potypus. 

Fissure and ulceration are causes because people thus 
afflicted put off going to stool just as long as they can, on 
account of the pain that accompanies and follows the act of 
defecation. The others produce constipation because they 
obstruct the passage of the feces. 

Symptoms. 

Among the symptoms other than the irregularity and 
incompleteness of the stools may be mentioned headache, inat- 
tention to business, loss of memory, melancholia, sallow com- 
plexion, indigestion, loss of appetite, etc., besides a long train 
of nervous and reflex phenomena. Perhaps the most frequent 
and annoying reflex symptom that accompanies constipation is 
the frequent spasmodic contractions of the external sphincter 
muscle. Sphincteric spasm is excited every time the fecal mass 
presents itself at the anus and is not promptly expelled. Again, 
the sphincter is kept in a constant state of irritability when the 
feces collect in large quantities within the colon, sigmoid, or 
rectum, because of the reflex disturbances set up as a result of 
the pressing of the mass upon the very sensitive mucous mem- 
brane and anus. The result of all this is that the muscle 
becomes hypertrophied and very strong from the additional 
work. Frequently the spasm of the muscle is caused by the 
presence of a fissure in the mucous membrane caused by the 
expulsion of hardened feces. In fact, we believe that in most 
cases of constipation, accompanied by hypertrophy of the external 
sphincter, a careful examination will reveal the presence of a 
fissure, an ulcer, or both. The muscle now, instead of being a 
voluntary help in the act of defecation, forms an obstruction 
beyond control of the will and only aggravates the condition 



256 DISEASES OF THE RECTUM AND ANUS. 

that originally gave it birth. In another part of this chapter 
we mentioned the fact that certain local conditions of the 
rectum might be put down as causes of constipation ; here we 
wish to say that constipation is the most frequent cause of rectal 
disease, and that any one of the following local diseases of the 
rectum and anus may be a symptom of constipation : — 

1. Anal fissure. 4. Prolapsus. 

2. Ulceration. 5. Proctitis and periproctitis. 

3. Hemorrhoids. 6. Neuralgia and coccygodynia. 

Anal Fissure. — When an action has been deferred for 
several days the feces accumulate ; the watery portion is ab- 
sorbed ; they become dry, hard, nodular, and very difficult to 
expel, ofttimes making a rent in the mucous membrane that 
eventually becomes an irritable fissure. 

Ulceration. — Ulceration of the rectum and of the sigmoid 
is a frequent symptom of persistent constipation, because the 
pressure on the nutrient blood-vessels by the fecal mass causes 
a necrosis of the tissues. 

Hemorrhoids. — Constipation is productive of hemorrhoids 
in several ways ; firstly, because of the obstruction to the return 
of the venous blood ; secondly, because of the venous engorge- 
ment of the hemorrhoidal veins during the violent and prolonged 
straining every time there is an action ; thirdly, because of the 
general laxity of the tissues in those suffering from constipation. 

Prolapsus. — A prolapsus of the mucous membrane or of 
the rectum may be caused by the fecal mass's pushing it down in 
front of the mass when an action does occur. Again, prolapsus 
may be the result of a paresis of the bowel caused by pressure 
of the mass on the nerves. 

Proctitis and Periproctitis. — An inflammation of the rec- 
tum and surrounding tissues, that may or may not terminate in 
abscess and fistula, is frequently caused by constipation as a re- 
sult of injury to the very sensitive mucous membrane by the hard- 
ened feces ; and, further, from the fact that feces, when long re- 
tained, undergo decomposition and expose any unsound portion 



CONSTIPATION. 257 

of the mucous membrane to the many septic organisms contained 
within them. 

Neuralgia and Coccygodynia. — The fecal mass within the 
sigmoid sometimes presses upon the neighboring nerves, causing 
reflex pains to be felt in the region of the sacrum and coccyx ; 
such pains are usually diagnosed as neuralgia of the rectum, or 
coccygodynia. 

In addition to causing the diseases just enumerated, con- 
stipation will aggravate any other disease of the rectum or colon 
that might be present. It at once is obvious that the treatment 
of constipation should be perfectly understood by all who may 
confine their practice to rectal and anal diseases. 

Treatment. 
Many papers have been written outlining the treatment of 
this annoying condition, and a thousand and one remedies have 
been recommended for its relief, and almost as many have proven 
failures. It is a question if there have not been more cases of 
persistent constipation caused by strong purgatives than have 
been cured by them. "We wish to state that we believe that 
certain tonics and mild laxatives (preferably reputable mineral 
waters) are of great value in the beginning of constipation ; 
and, further, that they sometimes do good in constipation of the 
worst form. All who have treated many cases of constipation, 
however, must have noticed how quickly the remedies prescribed 
for the relief of this condition lose their power. The dose has 
to be repeated or, still better, a new drug substituted ; in a short 
time another must be selected, and so on until both patient and 
physician are disgusted. In our own practice we have not used 
any medicine for a number of years in the treatment of consti- 
pation. Our results have been markedly better since we 
adopted our present plan. We do not wish to go on record as 
stating that we can cure all cases of constipation without med- 
icine ; but we desire to say that almost every case can be 
benefited, and a very large percentage of them perfectly cured, 

17 



258 DISEASES OF THE RECTUM AND ANUS. 

without any medicine whatever, — a fact that we have demon- 
strated in private practice and to classes at the University Med- 
ical College many times. The plan that we follow we have 
designated the 

NON-MEDICINAL METHOD. 

This method of treating chronic constipation has been 
outlined before by us in a number of medical societies and in 
periodicals during the last four years. We first called attention 
to this method of treatment at the Kansas City Academy of 
Medicine in January, 1891. Then before the Jackson County 
Medical Society of this city, in February, 1892; next at the 
Missouri Valley Medical Society at St. Joseph, Mo., March 16, 
1893. The paper last mentioned appeared in the Medical 
Herald the same month. The suggestion came to us through 
our operations for the relief of certain pathological conditions 
about the anus wherein the external sphincter muscle had been 
divulsed to insure complete rest. Our patients would frequently 
remark that we had cured them of their constipation as well. 
At first we did not understand how it happened ; but, after 
studying the matter closely, we came to the conclusion that it 
must be due to the dilatation, and, on referring to Allingham's 
work on rectal diseases, we found that he had had the same 
experience and advised divulsion as one of the essential features 
in the treatment of constipation. We then tried it in a number 
of old cases that we had attempted to cure by medication, and 
the results were very satisfactory, but not all that we had hoped 
for. In some the benefit was permanent, while in others it was 
only temporary ; we came to the conclusion that other features 
must be added to the treatment in order to combat successfully 
this annoying condition. After experimenting with a large 
number of cases we added the following features, which we 
practice, as a routine, after any local condition that might aggra- 
vate the costiveness has been corrected : — 

1. Divulse the sphincter. 

2. Practice frequent abdominal massage. 



CONSTIPATION. 259 

3. Use copious injections of warm water into the colon and 
the rectum. 

4. Apply electricity over the abdomen and per rectum. 
That part of the treatment just referred to must be carried 

out by the physician ; the patient, too, must do his duty by 
observing the following rules : — 

5. Go to stool daily and as near the same hour as is 
convenient. 

6. Correct errors in diet. 

7. Drink an abundance of water and eat sufficient fruit. 

8. Take plenty of out-door exercise daily. 

9. Take a cold bath every morning, to be followed by 
thorough rubbing. 

10. Dress warmly in winter and coolly in summer. 

11. Change occupation or climate if the case demand it. 

12. Be temperate in all things. 

Dilatation. — When the constipation is caused or made 
worse by an hypertrophied sphincter, or a spasm of the same from 
any cause, thorough divulsion should be practiced at the earliest 
opportunity, and great care must be taken not to lacerate the 
muscle. We have a case of complete incontinence under treat- 
ment at the present time, caused by a too rapid and careless 
divulsion. Dilatation can be accomplished in two ways, either 
by immediate or gradual divulsion. the first to be done under 
an anesthetic, by inserting the two thumbs into the anus and 
stretching the muscle thoroughly in every direction until there is 
no resistance. Many dilators have been devised for this purpose 
(see pages 169 and 170), but none of them have any advantage 
over the fingers, and are more apt to do injury to the bowel. 
Gradual divulsion is selected in cases where an anesthetic is 
deemed unsafe and where the patient's consent cannot be 
obtained to take the same ; it can be accomplished also by the 
aid of almost any of the many forms of rectal bougies. We 
prefer the soft rubber (Wales's), which can be had in any size. 
The Wales bougies are about twelve inches (3 decimetres) in 



260 DISEASES OF THE RECTUM AND ANUS. 

length and have an opening through the centre through which 
the colon and the rectum can he douched if the occasion 
demand it. They are better than the short Pratt or the Ideal, 
because in addition to the dilatation they seem to act as an 
irritant to the sensitive mucous membrane, reach higher up the 
bowel, and excite renewed peristaltic action. It is better to 
commence with a small size, — say, a No. 6, — leave it in a few 
minutes, until the muscle becomes used to it, when a larger size 
may be selected, and so on until a No. 12 can be introduced 
with ease. 

It is better to do too little than too much at the first sitting, 
for sometimes the sphincter is very stubborn and requires care- 
ful handling or its irritability will only be increased. Patients 
come to our office two or three times each week, the bougies 
are introduced and allowed to remain within the bowel until 
spliincteric resistance is overcome, and many times their with- 
drawal will be followed by a copious stool. Immediate divul- 
sion is seldom required more than once if a large-sized bougie 
is used from time to time afterward, just as in gradual divulsion. 
When thorough dilatation has been accomplished the muscle, 
instead of acting as an impassable barrier to the discharge of 
the feces, now offers only passive resistance, sufficiently strong, 
however, to prevent any unpleasant accidents, yet not strong 
enough to resist the power of the expiratory muscle when 
brought into full play during defecation. As a result of this, 
any large quantities of feces that have accumulated can be ex- 
pelled, thus doing away with one of the sources of irritation, 
and the tonicity and sensibility of the bowel may be restored 
from the pressure's being taken off neighboring nerves. 

Abdominal Massage. — This we regard as one of the most 
essential features in the treatment of habitual constipation. 
Massage is quite ancient, having been practiced by Hippocrates. 
It was not until quite recently, however, that the physicians at 
home and abroad recognized in it a powerful remedial agent if 
properly handled, and gave it their scientific attention, thereby 



CONSTIPATION. 261 

lifting it out of the hands of " charlatans " and " robbers," 
where it had long been left. We have been practicing it exten- 
sively during the last four or five years, in connection with other 
features mentioned in the treatment of constipation, and have 
found it to be a most valuable adjunct. With the patient in 
the recumbent position on a table (Allison's) which can be 
manipulated in such a way that the head may be raised or low- 
ered and the body rotated from side to side, that the intestines 
may be changed from one position to another, we make gentle 
but firm pressure, with the palm of the hand and ball of the 
thumb over the large intestine, beginning in the right iliac fossa. 
The course of the colon is followed into the left, accompanying 
the pressure by kneading the parts thoroughly with the fingers. 
This same procedure should be gone over several times, and 
should occupy in all about ten or twelve minutes. In the be- 
ginning the massage should be practiced every other day ; later 
on in the treatment, twice a week will suffice. 

Besides massage of the large intestine, special massage 
must be given to the liver and small intestine when there is a 
diminution in the amount of bile discharged and of the intes- 
tinal secretions. The patient cannot give himself massage, be- 
cause every effort on his part will be followed by contraction of 
the abdominal muscles, which prevents deep manipulations. If 
a patient is unable to pay for the treatments, we would recom- 
mend, as do the German physicians, that he take a metal ball 
or one of those used for bowling, weighing from three to five 
pounds, covered with cloth to prevent chilling the skin, and 
while in the recumbent position roll it daily over the course of 
the colon. 

Massage renders valuable assistance in the treatment of 
constipation in several ways : — 

1. It improves the circulation and stimulates the nerve- 
centres to renewed action. 

2. It loosens adhesions and dislodges and breaks up fecal 
impaction. 



262 DISEASES OF THE RECTUM AND ANUS. 

3. It restores tone to fatigued and inactive muscular fibres. 

4. It excites the liver and intestinal glands to renewed 
action. 

5. Altogether it assists normal peristalsis to take place. 

Copious Warm-Water Injections. — In beginning the treat- 
ment of constipation much benefit can be had from daily injec- 
tions of warm water when properly given ; they soften any fecal 
mass that might be lodged in the bowel and allow it to be dis- 
charged. It is not sufficient to flush the rectum alone, but the 
colon should be reached as well, for the feces become impacted 
more frequently in the latter than in the former. To do this 
well one must have a colonic tube from eighteen to twenty- 
four inches (46 to 61 centimetres) in length and a good 
syringe, — preferably a Davidson, bulb, hard-rubber piston, or 
a fountain, — the nozzle of which can be inserted into the tube. 
The syringe is then filled and the patient requested to place 
himself in the Sims or recumbent position. When the tube 
has been well oiled with some stiff lubricant, it is passed slowly 
and gently up the bowel until it becomes lodged beneath a fold 
of the bowel. A few ounces of water are then allowed to pass 
through it; at the same time pressure is made upward with the 
tube. In this way the fold will be lifted upward out of the way 
each time the tube meets with resistance ; the same procedure 
must be gone through with until the tube is well within the 
colon. Then let the water run until the colon is distended. It 
will take anywhere from half to a gallon of warm water, or more, 
depending upon the amount of feces present. The water should 
be retained as long as possible that it may permeate the mass. 
The injections may be kept up until normal peristaltic action 
and glandular secretion have been re-established, and no longer. 

It has been demonstrated frequently that when normal 
defecation is interfered with by daily injections of water (Hall 
treatment), the bowel makes no attempt to get rid of the con- 
tents, but patiently awaits the convenience of the interested 
person and the injection which relieves it of all duties. 



CONSTIPATION. 263 

Electricity. — Electricity has been very highly recommended 
by many writers on the treatment of constipation. We have 
used it a number of times with varied success. Some prefer 
galvanism, others faradization. One pole may be placed over 
the spinal column and the other moved about over the course 
of the colon, or one over the spine and the other within the 
rectum. As yet, we have not been convinced that electricity 
alone is sufficient to cure very persistent cases of constipation, 
but are quite positive that much benefit can be had when 
it is properly used in conjunction with dilatation, massage, etc. 
Its action is similar to that of massage in that it restores mus- 
cular tone and glandular activity. 

The features of the treatment just referred to should be 
carried out by the physician himself, while those to follow are 
to be practiced by the patient under the supervision of the 
physician. 

Go to Stool Daily at the Same Hour. — Patients should go 
to stool daily at the same hour (preferably just after the morning 
meal). This may seem unimportant, but experience has shown 
us that the bowel can be educated to act at the same hour daily ; 
or, on the other hand, not more than once in two or three days 
in those who are careless in their habits. This mav not be 
accomplished in those who have persistent constipation, at first, 
but if they will persevere in going to the closet at or near the 
same time every day, and devote their entire time while there 
to the expulsion of the fecal contents, and not make it a reading- 
room, they will bring about the desired result. Patients are 
prone to become discouraged at first ; they should be informed 
that it does not make any difference so far as the ultimate result 
of the treatment is concerned if the bowel does not act regularly 
during the first few days. 

Correct Errors in Diet. — This is one of the most essential 
features in the treatment. All foods known to disagree with 
patients should be discarded. We shall not have space to lay 
down a fixed diet-list, but desire to say that it should consist as 



264 DISEASES OF THE RECTUM AND ANUS. 

far as possible of easily-digestible foods, intermediate between 
meat on the one hand and milk on the other, and, in children, 
proportionately rich in fats, albuminoids, and sugars, while poor 
in starches. All meals should be served at regular hours and 
under pleasant surroundings ; it has been observed that digestion 
is more or less interfered with during anger and sorrow. 

Drink an Abundance of Water. — There are few better 
laxatives than a glass of cold or hot water, taken upon an 
empty stomach before breakfast. Water prevents the feces from 
becoming dry and impacted. A reasonable amount of fruit, 
such as apples, oranges, and figs, should be eaten ; they will do 
much toward relieving the constipated condition. 

Take Sufficient Out-door Exercise. — Persons suffering from 
constipation should take regular out-door exercise; and, if con- 
venient to a gymnasium, we would recommend that they spend 
half an hour each day developing the various muscles of the 
body. There is not a question but the Germans, who are noted 
for their out-door sports and gymnastic exercises, suffer much 
less from constipation than we Americans, who do not take time 
to do anything but work for the "Almighty dollar." 

Take Baths Daily. — The best time to take them is before 
breakfast. The colder the water, the better ; the bath should 
be followed by a thorough rubbing of the skin with a Turkish 
towel. This stimulates the circulation, increases peristalsis, and 
opens up the pores of the skin. Assimilation will then take 
place. Altogether one feels like a new man and ready to under- 
take the arduous duties before him for the day. 

Dress to Suit the Season. — It is a well-known fact that cold 
is conducive to constipation and warm weather to diarrhea ; 
hence it is very essential that we should dress warm in winter 
and cool in summer. 

Change of Business and Location. — This is absolutely 
essential in some cases of persistent constipation, when all other 
means have failed to be of any benefit. It is a recognized fact 
that a sedentary occupation is a frequent cause of constipation, 



CONSTIPATION. 265 

and that a change to a more active one in the open air will 
sometimes cure it, and, further, that persons who suffer from 
constipation in one climate are relieved when they change to 
another. Admitting these to be facts, we think we are justified, 
in certain very obstinate cases, in insisting that the patient shall 
change his occupation, his location, or both. 

Be Temperate in All Tilings. — Excesses and irregularities 
in living play an important part in producing and prolonging 
constipation ; hence moderation in the manner of living should 
be encouraged. 

Altogether we have treated 250 cases of obstinate consti- 
pation by the "non-medicinal method." Of this number 140 
were females and 110 were males, their ages ranging from 
infancy to 85 years. The following table will show the results 
of .the treatment : — 

Cured, 150 

Marked improvement in, . . . . .60 

Slightly improved, 15 

Unimproved, ........ 25 

Total, 250 

In a short time we expect to publish a book on constipation 
and diarrhea, and their non-medicinal treatment. 



CHAPTER XXIV. 

IMPACTION OF FECES. 

The impaction of feces may be due to numerous causes. 
Frequently it is due either to a loss of muscular tonicity or to 
some paralytic affection, and sometimes is a result of the quality 
of the food eaten. This was demonstrated during the Irish 
famine of 1846, when potatoes of a very inferior quality were 
the only articles of diet. In fact, anything which will produce 
constipation may at times result in fecal impaction. Often some 
indigestible substance, as a plum-seed, etc., will be found in 
the centre of the mass, the fecal matter having collected around 
it much as the snow-ball collects the snow when rolled on the 
ground. The impaction, while usually found in the rectal 
pouch, may take place in any part of the colon. Hence, if we 
suspect we have a case of impaction and do not find it in the 
rectal pouch, we should examine the sigmoid and the colon 
thoroughly. While it occurs more frequently in elderly per- 
sons, no age is exempt. Women are more liable to have impac- 
tion than men, owing to their irregular habits, pregnancy, etc. 

Symptoms. — The symptoms, indicated by the collection of 
large fecal concretions, may become formidable by producing 
constipation. There may be a sense of weight and fullness in 
the rectum and severe bearing-down pains similar to those dur- 
ing labor. The pains, however, may be reflected up the back, 
down the loins, or to the abdomen. The last symptom, together 
with the diarrheal discharges which are sometimes present, are 
very misleading ; and a careful examination should be made to 
detect the accumulated mass. Simply because a patient has a 
slight movement daily is not a sure sign that there is no im- 
paction, for the liquid feces may be discharged around the mass. 
As the accumulation increases the symptoms may become ex- 
aggerated. There may be vomiting, coldness of the feet, jaun- 
(266) 



IMPACTION OF FECES. 267 

dice, and shooting pains down the limbs. A collection of feces 
in the colon or the rectum may be mistaken for morbid growths 
which occur in these localities, or for an enlarged prostate or 
uterus. The diagnosis can usually be made, however, by intro- 
ducing one finger high into the rectum and the vagina, while 
palpation is made over the course of the colon with the other 
hand. In this way the mass can be located. 

Treatment. — This consists in the early removal of the entire 
mass, which may be done in a variety of ways. If the case be 
an urgent one, the sphincter should be thoroughly dilated and 
the mass removed in segments, either by the finger or the handle 
of a spoon. This will be materially hastened by the injection 
of large quantities of soap-suds through a long rubber tube in- 
troduced into the rectum or colon ; this to be determined by the 
location of the mass. If there is no indication of inflammation 
or ulceration, nothing will assist in breaking up the mass, when 
situated high up in the rectum or colon, more readily than ab- 
dominal and pelvic massage of the colon from right to left in the 
direction of the anus. In women, when the finger is introduced 
into the vagina and pressure made downward the mass may be 
dislodged. We have been in the habit of keeping the sphincter 
dilated with bougies and flooding the rectum and the colon with 
soap-suds daily for some time after the accumulation has appar- 
ently disappeared, and we have been much pleased with the re- 
sults. We never use purgatives for the reason that the obstruc- 
tion is purely mechanical and is concentrated. We sometimes 
prescribe a mild laxative after the mass has come away, if there 
is a tendency to constipation, but we prefer to overcome the 
latter by massage, regular habits, etc. The treatment for con- 
stipation has been fully treated of in the previous chapter. 



CHAPTER XXV. 
ATJTO-INFECTIOX FROM THE INTESTINAL CANAL. 

As we understand it, auto-infection from the intestinal 
canal means that pathological condition resulting- from the ab- 
sorption of poisons generated within it. It matters not whether 
they are the result of chemical, putrefactive, or fermentative 
changes or bacterial action. 

We give this topic a distinct caption because we are sure 
its importance has been very much underrated, and because it is 
a subject that writers on rectal diseases heretofore have ignored. 
This is surprising, too, when experiments have shown that, in 
the main, poisons are generated in the colon. That the organism 
might be poisoned by the products generated within it was, 
until quite recently, looked upon with much skepticism. To- 
day we are forced to admit that such a thing is of common 
occurrence. Recent investigators have given an abundance of 
proof that the various organs of the body — the brain, the liver, 
the lungs, the kidney, etc. — are frequently invaded by the 
bacillus coli communis and other micro-organisms and some 
pathological condition induced as a result thereof. They have 
gone a step farther than this and demonstrated the fact that 
toxic substances that are disease-producing, independent of 
bacterial action, are being constantly formed within us in 
health. 

As regards auto-infection from the intestinal canal, we have 
as yet very little proof of the absorption of poisons from this 
source or as to the manner in which it occurs. Many of our 
best clinicians and investigators, however, express themselves as 
believing that the cause of many diseases, the pathology being 
obscure at present, will be explained when we become more 
familiar with the part played by the contents of the human 
sewer. 

(268) 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 269 

We may have auto-infection from any portion of the in- 
testinal canal. It is claimed by some that it occurs more fre- 
quently in the small intestine than in the large, for the reason that 
here there is an increased amount of water in the feces that may 
be conducive to the solution and absorption of certain bacteria 
and their products. On the other hand, there are many who 
believe that auto-infection takes place more frequently from the 
large intestine (especially from the descending colon, the sigmoid, 
and the rectum) because the decreased watery elements leave 
the feces more nearly solid, and they remain longer and putre- 
faction takes place, affording a rich field for the multiplication 
of the septic micro-organisms and their products. These dis- 
turbing elements are taken up by the circulation and possibly 
by the lymphatics and thus disseminated to all parts of the 
body. Before we can intelligently study the trouble that might 
result from poisons created within the intestinal canal, we must 
familiarize ourselves with its normal contents. We shall men- 
tion only the gross contents of the large intestine for the reason 
that we intend to confine our study of auto-infection from the 
intestinal canal as far as possible to the colon. Grossly speak- 
ing, the contents are made up of refuse products of food, the 
excrementitious portions of the digestive fluid, water, gases, and 
animal alkaloids, together with a multitude of micro-organisms 
and their products. At present we know but little of these 
gases and alkaloids as regards their properties and action in 
health and disease, and the same may be said of the micro- 
organisms, with few exceptions. We cannot help believing, 
however, that in proportion as we become familiar with the 
poisonous agents contained in the digestive fluids and excreta 
we shall become more familiar with many diseases now called 
functional for the reason that we are not very familiar with 
their pathology. Perhaps Bouchard has done more work along 
this line than any other man. It was him who demonstrated 
the fact that many poisonous alkaloids are being constantly 
formed in the digestive secretions. In fact, this writer has said : 



270 DISEASES OF THE RECTUM AND ANUS. 

" The organism in its normal, as in its pathological, state is 
a receptacle and a laboratory of poisons. Some of these are 
formed by the organism itself, others by microbes, which either 
are the guests, the normal inhabitants of the intestinal canal, or 
are parasites at second hand, and disease-producing." He has 
shown that the peptones of normal digestion contain poisonous 
alkaloids, and a solution of them as they appear in the stomach 
as the result of gastric and, lower down, as a result of pancreatic 
digestion will, when introduced into the blood of an animal, 
produce general disturbances and death ; and also that a suf- 
ficient amount of poison to cause death in a short time is 
secreted by the kidneys when, from any cause, the poison is 
allowed to accumulate or is absorbed as a result of the urinary 
tract's becoming denuded of its epithelium from the tubuli of 
the kidney to the meatus. 

When w x e have renal suppression resulting in death, 
Bouchard attributes it to the absorption of poisons normally 
"secreted," and not to an accumulation of urea; and he says 
that a "complexity of phenomena is hidden under the name 
4 Uremia.' " 

Park, under the caption of " Intestinal Toxemia," includes 
first a condition of unusual or at least undesirable activity in the 
contents of the intestinal canal, by which, whether due to com- 
mon or specific forms of bacteria, the ptomaines of putrefaction 
are produced in such a manner or of such a quantity that they 
are absorbed through the intestinal mucosa and are distributed 
over the body, by which a condition of intoxication is produced. 
In this form it is not meant to imply that any of these bacteria 
gain access to the circulation, but that a more or less profound 
toxemia is produced. Second, a form in which the common or 
uncommon bacteria met with in the intestinal canal pass into 
and infect the living tissues of the patient and produce local 
and general infection in addition to the toxemia above de- 
scribed. The first form occurs alike in medical and surgical 
cases. Here we have a demonstration, on the one hand, of how 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 271 

we may become intoxicated from the alkcdoidal poisons formed 
during digestion, and, on the other, as a result of unusual 
activity of bacteria — the normal inhabitants of the intestinal 
canal — and their ptomaines. As we become more familiar with 
the almost innumerable poisons within us, and their effect when 
injected into the lower animals, we are forced to admit that we 
are constantly tottering on the brink of self-destruction, and 
that we only need to disobey some one of nature's laws to upset 
the equilibrium and to fall a prey to some one of these poisons. 
Our Creator, however, foresaw all dangers and provided us 
abundantly with safeguards with which we can destroy or neu- 
tralize the poisons, on the one hand, or throw them off, on the 
other, as soon as they are formed. 

It becomes apparent, then, that for auto-infection to take 
place two things are essential : — 

1. There must be an impairment of physiological action 
somewhere. 

2. That poisons are being constantly formed in us in 
health. 

We know that in the physical system every cell has a duty 
to perform, and the same can be said of those aggregations of 
cells which we call organs. Impair or destroy a single one and 
the economy suffers, and the effect is in proportion to the im- 
portance of the work normally allotted to it. Now, if from any 
cause the liver, the lungs, the skin, the kidneys, or the blood 
should get out of order and fail to perform its function, what is 
the result ? Poisons that are being constantly secreted are not 
being rendered harmless, on the one hand, or are not being- 
thrown off, on the other, but are allowed to accumulate, enter 
the circulation (possibly lymphatics), and are distributed through- 
out the body, causing local or systemic infection, as the case 
may be. 

Again, the physical soil is prepared for absorption of poi- 
sons by anything that will cause a lesion of the intestinal mu- 
cosa or distend, press upon, or weaken the walls of the intestine, 



272 DISEASES OF THE RECTUM AND ANUS. 

such as the accumulation of feces, tumors, strictures, ulcerations, 
inflammations, operations, etc. 

Just so long, however, as the emunctorics are working in 
harmony and perform their individual functions and there is no 
lesion of the intestinal mucosa, all is well, and all poisons, 
no matter whether they are the products of decomposition 
or of bacterial action, will do no harm for the reason that they 
are thrown into a special reservoir (the liver), where they are 
destroyed or neutralized and afterward discharged from the 
body. Schiff ascertained that by injecting certain alkaloids 
into a branch of the portal vein the proportion of poison in the 
blood as it came from the liver was much lessened. The blood, 
however, constantly takes from the organs poisons as soon as 
they are formed and renders them inert, especially if the poisons 
are of bacterial origin. 

Recent investigations have demonstrated that the serum of 
arterial blood contains some substance (defensive proteids) that 
acts in one of three ways : First, by killing the bacteria (bacteri- 
cidal) ; second, by attenuating or weakening the bacteria ; third, 
by neutralizing or destroying the toxins. It has been shown 
that the blood taken from one animal that has been made im- 
mune against certain infective diseases (tetanus, diphtheria, etc.), 
when injected into another animal or human being, renders such 
animal or person immune to that disease; as yet investigators 
have been unable to isolate any one " defensive proteid " that will 
prove effective against infective diseases in general, but believe 
they will be able to accomplish this in the near future. Han- 
kin classifies defensive proteids into two groups: 1. Those ex- 
isting naturally in animals. It is a noted fact that the rat is 
immune to certain diseases to which the guinea-pig readily 
succumbs, and these are called sozins. 2. Those existing in 
animals artificially made immune, which he calls plvyloxins. 
For sub-classes he suggests the prefixes mico- and toxo- to 
indicate sozins or phyloxins which destroy bacteria, or which 
destroy their toxins. From the above it becomes apparent that 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 273 

the study of auto-infection is closely intermingled with that of 
immunity. 

It is at times very difficult to determine, in cases of auto- 
infection, where health leaves off and disease begins ; this is 
because of the fact that, on the one hand, these poisons are phys- 
iological factors, and, on the other, as soon as the system becomes 
susceptible, they become active pathological factors. 

We have neither the space nor inclination to attempt to 
classify and point out the pathological significance of the various 
poisons generated within the intestinal canal. Hence, we shall 
at first mention only those manifestations which are due to 
colon infection, those which are systemic in character, and those 
which are of the most frequent occurrence. 

Then we shall pay our respects to the colon bacillus (and 
associated bacteria) and endeavor to point out some of the patho- 
genic properties of this meddlesome little micro-organism which, 
we believe, will prove of interest alike to both the physician and 
the surgeon. 

Perhaps the most frequent and immediate cause of auto- 
infection is w ' constipation," and more especially when compli- 
cated by a fecal impaction. In the latter case we have the 
retention of the feces for a variable length of time ; as a natural 
sequence, effete matters accumulate in the bowel and, by re- 
maining, undergo chemical changes, and poisons of the ptomaine 
and leucomaine classes are formed, which are as active as any 
poisons that could be introduced from without, as, for examples, 
typhoid fever and cholera, wherein the bacillus runs its entire 
course in the intestine. 

As a result of the accumulation of poisons, we have sys- 
temic infection induced ; it may or may not run a chronic course, 
depending upon the removal of the offending mass. If nothing- 
is done to prevent the continued formation of poisonous prod- 
ucts, they soon manifest themselves in the clinical pictures 
with which all are more or less familiar, — chlorosis and anemia. 
Patients suffering from chlorosis or anemia come to us com- 

18 



274 DISEASES OF THE RECTUM AND ANUS. 

plaining of headache and a feeling of lassitude ; they have a 
feeling of lassitude on arising in the morning; they are im- 
patient and careless about attending to their usual duties; they 
do not care to read or talk, but are inclined to melancholia, pre- 
ferring to be left to themselves ; they are pale, have greenish- 
yellow complexion and a foul breath. They suffer from a 
depraved appetite, indigestion, palpitation, dizziness, and a host 
of other symptoms too numerous to mention. Too often they 
are treated for biliousness, malaria, or grip. They change from 
one physician to another until one is found who makes a correct 
diagnosis and succeeds in removing the feces and cures his 
patient without any medicinal treatment whatever. Many 
patients suffering from fecal toxemia become so saturated that 
they look not unlike a person with a malignant growth in an 
advanced stage. For the sake of illustration, let us study the 
phenomena in a case of extreme intoxication from the intestinal 
canal to ascertain its effect upon the various systems and skin. 

1. Circulatory system. 3. Skin. 

2. Respiratory system. 4. Nervous system. 

The Circulatory System. — As a result of auto-intoxication 
we have a disturbance in the circulation; the cutaneous vessels 
become contracted, thus throwing an increased amount of blood 
into the central organs, and the body's equilibrium is interfered 
with. The pulse may be slow and full, on the one hand, or 
rapid and feeble, on the other, depending upon the extent of the 
intoxication and its influence upon the muscular fibres of the 
heart and upon the nervous system. Frequently the heart is 
very excitable and patients have fainting spells. Sometimes, 
instead of the blood being retained in the central organs, it 
seems to remain in the extremities and causes a dilatation of the 
veins. Hemorrhoids are almost invariably present in those who 
suffer from auto-intoxication for a considerable time. 

TJie Respiratory System. — The effects of auto-infection on 
the respiratory system are not so numerous as they are on the 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 275 

circulatory or nervous systems. Their effects are shown more 
quickly and in a more aggravated form when the intoxication 
is complicated with some lung trouble ; and, vice versa, all lung 
diseases become markedly worse when there is systemic intoxica- 
tion, for there is deficient oxygenation of the blood. It would 
appear, from recent investigations, that the colon bacillus plays 
an active part in the causation of some forms of pneumonia and 
of empyema, but more frequently when there is a lesion of the 
intestinal mucosa. When the lungs are diseased the gravity is 
in proportion to the amount of tissue involved ; when this is 
extensive and death ensues, it is due to auto-infection, — a result 
of the accumulation and absorption of carbonic acid and other 
poisonous elements that should have been eliminated by the 
lungs. 

The Skin. — The skin shows the effect of the intoxication 
in its pale, muddy, unhealthy color, foul-smelling secretions, and 
in any one of the many skin diseases. 

The Nervous System. — When there is auto-infection to any 
very great degree it manifests itself in some of the many nervous 
phenomena that we see so frequently in our everv-day practice. 
One of the most frequent manifestations is a feeling of drowsi- 
ness, due to the effect of the absorption of one of the intestinal 
gases, likely that of sulphuretted hydrogen, which is known to 
have a soporific effect. Though the patients feel drowsy, they 
are poor sleepers ; they roll and toss about the bed ; they are 
frequently awakened by horrible dreams, or find themselves 
wandering about their rooms. In the morning, when they arise, 
they do not feel refreshed ; but, on the contrary, they feel weak, 
exhausted, and find their clothing moist by a clammy, unhealthy 
perspiration. 

W^e believe that a very large percentage of all headaches 
and neuralgias are due to auto-infection, it matters not where 
the pain is located. For we have many times witnessed the dis- 
appearance of headaches after the bowels had been completely 
emptied, without the assistance of a single dose of medicine. 



'J7(> DISEASES OF THE RECTUM AND ANUS. 

Our neurological friends claim that a number of nervous func- 
tional diseases are often produced, as a result of a fecal toxemia. 
Neurologists have proven, from a clinical stand-point, that some 
forms of insanity are undoubtedly caused by auto-infection from 
the intestines, due to the absorption of gases or poisons of the 
ptomaine and leucomaine classes. Epileptics nearly always have 
fewer attacks so long as the colon is kept cleaned out ; some au- 
thorities believe that not a few cases could be cured if we would 
direct our attention to the intestinal canal, and through our 
treatment prevent the accumulation and absorption of the man- 
ifold poisons generated therein. Thus far, in speaking of auto- 
intoxication, we have incidentally mentioned constipation and 
fecal impaction as the prime factors in opening a way for the 
production and absorption of poisonous products. We should 
not do the subject justice, however, were we to leave the 
impression that infection occurs only when there is obstinate 
constipation. We have frequently treated patients who were 
unquestionably suffering from auto-infection, and nearly all, 
if not all, evinced the phenomena previously mentioned. Yet 
they gave no history of constipation ; but, on the contrary, the 
intoxication was presented through a chronic diarrhea, and from 
other causes which we were unable to determine. Park tells 
us : " There takes place within the intestinal laboratory such a 
putrefaction as produces ptomaines which are at the same time 
toxic and cathartic in their action, so that the irritating material 
is expelled by virtue of the very poisons it has produced ; and 
it furthermore often happens that the exhibition of a vigorous 
cathartic — for instance, one of the mercurials — will so admirably 
clean out the entire intestinal canal that not merely is the entire 
action prevented or checked when present, but that a most 
happy effect is exerted upon septic disturbances commencing 
elsewhere." 

We have personally treated not a few patients suffering 
from an ulceration of the colon or the rectum where the ulcers 
were small and not unhealthy-looking, wherein the patients 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 277 

were affected by systemic intoxication. They were very much 
emaciated, extremely nervous, had sallow complexions, were 
inclined to be melancholic, and, in fact, had all the symptoms 
likely to accompany auto-infection. Diarrhea is ever a promi- 
nent symptom of ulceration, and it complicates matters by 
rendering soluble and distributing the poisonous elements in the 
feces to any exposed point of the mucosa, thereby insuring their 
entrance into the circulation and spreading desolation anywhere 
they go. Xot all cases of ulceration of the rectum and the 
colon are complicated with systemic infection, because many 
times the poisons are rendered inert or are thrown off before 
they have a chance to do much harm. Perhaps the most typical 
cases of auto-infection from the intestinal canal are to be found 
in patients suffering from stricture of the rectum and colon. 

It is here that we find the two conditions that are favorable 
to auto-infection : fecal impaction above the point of constriction, 
on the one hand, and frequent stools, on the other, induced by 
a reflex peristalsis. The former prepares the field by causing a 
distribution and ulceration of the walls of the bowel and at the 
same time offers a good culture-medium for the micro-organisms 
and favors putrefaction and fermentation, while the latter renders 
the poisons capable of being scattered about. As a result, more 
poisons are generated and absorbed than nature can take care 
of; the system becomes saturated with them and such sufferers 
look almost as bad as if they were infected with a malignant 
growth. In fact, any disturbance of the rectum and the colon 
that will cause a diarrhea or constipation predisposes the indi- 
vidual to auto-infection and its many evils. 

We have in the preceding pages called attention to some 
general manifestations which we believe are caused by the ab- 
sorption of septic material from the intestinal canal. We now 
invite your attention to the study of a number of diseases in and 
around the rectum and other organs, which, if not directly caused 
by intestinal bacteria, are certainly aggravated and continued 
through their instrumentality. As for the single germ of 



278 DISEASES OF THE RECTUM AND ANUS. 

intestinal origin, the most frequent disturber in neighboring and 
distant parts, the colon bacillus communis leads them all. This 
germ seems to be the king of disturbers and has been found in 
nearly all the organs of the body, and under circumstances that 
have led investigators to believe that it unquestionably has 
pyogenic properties. Many other germs, with known patho- 
genic properties, have been proven to be identical with this 
bacillus ; and at present it is considered identical with the fol- 
lowing organisms : The bacillus Neapolitanus, Brieger's feces 
bacillus, Passet's bacillus pyogenes feet id 'us, the urinary pyogenic 
bacterium (Clado and Albarran), which Morelle and Krogius 
considered identical with the bacillus lactis aerogenes and the 
urobacillus septicus, and as the septic bacterium discovered by 
Bouchard. Familiarity with this bacillus is so important, alike 
to the physician and the surgeon, that we will discuss it in 
detail. 

The following description of the appearance, growth, prop- 
erties, pathogenesis, etc., of the bacillus coli communis we copy 
from Ball* because of its brevity : — 

" Bacillus Coli Communis (Escherich). 

" Found in the human feces, intestinal canal of most animals, in 
pus, and water. 

" Form. — Short rods with very slow movement, often associated 
in little masses resembling the typhoid germ. 

" Properties. — Does not liquefy gelatin, causes fermentation in sac- 
charine solutions in the absence of oxygen, produces acid fermentation 
in milk. 

" Growth. — On potato a thick, moist, yellow-colored growth. Very 
soon after inoculation on gelatin a growth similar to typhoid. It can 
also develop in carbolized gelatin, and withstands a temperature of 45° C. 
without its growth being destroyed. 

11 Pathogenesis. — Inoculated into rabbits or guinea-pigs, death fol- 
lows in from one to three days, the symptoms being those of diarrhea and 
coma ; after death tumefactions of Peyer's patches and other parts of the 
intestine ; perforations into the peritoneal cavity, the blood containing a 
large number of germs. 

* Essentials of Bacteriology, by M. V. Ball, M.D. Second edition. 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 279 

" Staining. — Ordinary stains ; does not take Gram. 

" Site. — The bacillus has been found very constant in acute peri- 
tonitis aud in cholera nostras. Its presence in water would indicate fecal 
contamination. 

" The growth on potato, the effect on animals, and its action toward 
milk are points of difference from the typhoid bacillus." 

We take this occasion to state that we have made no per- 
sonal experiments as regards pathogenic and pyogenic properties 
of the bacillus coli communis; hence we shall quote in extenso 
from those who have made a special study of this organism and 
endeavor to show, by their experiments and arguments, the part 
played by this normal inhabitant of the intestinal canal in 
causing disease under varying circumstances. 

Roswell Park,* in speaking of the bacillus coli communis, 
relates the following history concerning it : '■ It was first de- 
scribed in 1885 by Escherich, and was first regarded as a 
saprophyte and intestinal parasite. In 1887 Hueppe found it 
in the stools of a patient suffering from cholerine. Its positive 
pathogenic properties were first made known by Lauelle in 
1889, then by Tavel. also by Eodet and Roux. who fully estab- 
lished its pyogenic properties." He goes on to say that it is a 
short, rod-shaped organism, its shape causing it to be generally 
known as the bacillus coli communis, which in the hanging drop 
is motile, its motility consisting in a sort of oscillation, and 
sometimes with a rapid translation. Its possession of flagella is 
disputed ; at most, it does not have more than three of them, 
while the typhoid bacillus possesses from eight to twelve. It 
seems to enjoy a sort of commensalism, possibly even a sym- 
bosis. In the healthy intestinal canal it practically never exists 
alone, but it is found alone in other parts of the body under 
certain conditions. Ordinarily it is not virulent, but under 
certain circumstances its virulence varies within wide limits, as 
is shown when it is obtained from cholera nostras, and, inoc- 

* " Surgical Importance of the Bacillus Coli Communis/' Annals of Surgery, Sep- 
tember, 1893. 



280 DISEASES OF THE RECTUM AND ANUS. 

ulated. it causes death from acute septic infection within twenty- 
four hours. When from intra-abdominal abscesses, it is only 
slightly infectious. We have to deal with this organism, then, 
under two conditions : first, as an exceedingly active agent, pro- 
ducing acute septic infection ; second, as a common pyogenic 
organism, producing local abscess. 

Pathogenic Action. — To show the pathogenic action of the 
colon bacillus we quote from a paper by Dr. Welch, of Balti- 
more, read before the Second Congress of American Physicians 
and Surgeons. He said : — 

" Tavel's observations of the colon bacillus in connection with wound- 
infection were followed by a few isolated observations of this organism, 
either in the unchanged organs of the bod}- or in suppurations, until re- 
cently. A. Frankel reports its presence in 9 out of 31 cases of peritoni- 
tis. I first came across this bacillus in the organs of the body in 1889-90, 
in a case of multiple fat necrosis with pancreatitis, which I reported to 
the Association of Physicians. As in this case diphtheritic colitis ex- 
isted, it seemed probable that the lesions in the intestine opened the way 
for the entrance into the circulation of this inhabitant of the healthy 
intestinal canal. This view subsequent experience has confirmed. 

"I have almost uniformly failed to find it outside of the intestinal 
wound when no demonstrated lesion of the mucous membrane existed. 
I am, therefore, prepared to say that this bacillus is an extremely frequent 
invader in intestinal diseases, Moreover, the colon bacillus does not in- 
vade the blood and organs in the process of post-mortem decomposition. 

" The cases in which we have found the colon bacillus under cir- 
cumstances pointing to its pathogenic action have been as follows : Per- 
forative peritonitis, 4 cases; peritonitis secondary to intestinal disease 
without perforation, 2 cases ; circumscribed abscess, 3 cases; and lapa- 
rotomy wounds, 6 cases. 

" Its presence several times in pure culture, in laparotomy wounds 
treated aseptically, although apparently not a source of serious trouble, 
was not a matter of indifference. It was generally accompanied with 
moderate fever, and with a thin, brownish, slightly-purulent discharge, of 
somewhat offensive, but not putrefactive odor. 

u The smooth and rapid healing of the wound was interfered 
with. In some of the cases there was evidence of intestinal disorder; 
in others this was not apparent, and infection from without could not be 
excluded. 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 281 

" For the purpose of the present discussion, perhaps the chief in- 
terest of our observations concerning the colon bacillus is that they 
furnish illustration of the predisposition to infection afforded b}- intes- 
tinal lesions, and also give example of the much-disputed auto-infection.''' 

Park, at the same meeting, spoke of enterosepsis in cases 
of abdominal surgery produced by this bacillus. He said that 
under some circumstances it either escapes or is carried beyond 
its normal limits, and, entering the portal circulation, perhaps 
the lymphatics as well, appears to set up septic disturbances 
which are typified by the production of septic peritonitis, and 
possibly other forms of septicemia in which the peritoneum 
does not primarily figure, — a condition which Drs. Welch and 
Councilman call colon infection. 

We shall not attempt to do more than mention a few of 
the diseases in which the colon bacillus appears to be the most 
active agent. It has been known to manifest its presence in the 
following conditions : — 

1. Infectious diarrhea. 

2. Empyema (following enteritis). 

3. Broncho-pneumonia. 

4. Endocarditis. 

5. Cystitis. 

6. Nephritis and pyelonephritis (surgical kidney). 

7. Disorders of the liver (icterus). 

8. Appendicitis. 

9. Periappendical abscess. 

10. Perforative peritonitis (also in cases of lesions of that 
intestine without a perforation). 

11. Laparotomy wounds. 

12. Strangulated hernia (in fluid of). 

13. Perirectal abscess, etc., etc. 

A casual glance at the above diseases in which this germ 
is Jcnoiun to be an etiological factor is sufficient proof of its 
having pathogenic and pyogenic properties. Until quite recently 
it was supposed that this germ did not enter the circulation and 



282 DISEASES OF THE UECTUM AND ANUS. 

produce disease in distant parts unless there was a lesion of the 
intestinal mucosa. We are to-day taught by such excellent 
authorities as Welch, Park, Councilman, and others that the 
bacillus coll communis is capable of entering the circulation, 
whence it is carried, and does produce disturbances independent 
of any intestinal lesion. It is quite easy to understand the way 
in which it reaches and infects the genito-urinary tract and the 
liver. It is usually introduced into the urethra, bladder, and 
from thence to the kidneys through the ureters, by means of an 
unclean sound or other instruments. Some writers allege that 
the colon bacillus sometimes passes through the rectal wall and 
starts up a cystitis, when the mucous membrane is ready to 
receive it. 

As to reaching the liver, this normal inhabitant of the in- 
testinal canal has but to walk leisurely, as it were, up the in- 
testine and through the door of the common bile-duct to gain 
access to her " Majesty's innermost chambers," causing an in- 
fection therein. It is remarkable that w r e do not see biliary 
infection more frequently than we do. 

We wish now to pass to that portion of the subject which 
is of more especial concern to those who are interested in rectal 
and anal diseases. We have for a considerable time past inclined 
to the belief that the colon bacillus or some other bacteria, either 
alone or combined, directly or indirectly cause proctitis and peri- 
proctitis. 

Proctitis, if allowed to run an uninterrupted course, almost 
invariably results in abscess, fistula, or a stricture, as the result 
of the lumen of the bowel being diminished by inflammatory 
deposits, or as a result of vicious cicatrization following ulcer- 
ation. If future investigations prove that these intestinal 
bacteria are the starters of the inflammation and incidentally 
the sequel which follows, we shall, in all probability, have the 
explanation of the cause of a large percentage of strictures that 
are at present classified as being due to "unknown causes"; 
for they cannot be assigned to traumatism, syphilis, tuberculosis, 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 283 

dysentery, etc. We have personally made no investigations to 
determine this fact, but hope to do so in the near future. For 
the present we shall have to base our remarks upon the facts 
brought out by men who have done original work along this 
line, — namely, Welch, Park, and Councilman. 

In order to obtain the latest information relative to this 
important subject we wrote to Dr. Park, of Buffalo, and to Dr. 
Welch, of Baltimore, asking their opinions as to auto-infection, 
the part played by the colon bacillus in the same, and, if any. 
what part this bacillus plays in the causation or continuance 
of certain local diseases of the colon and rectum, such as 
proctitis, abscess, etc. We have misplaced the copy of this 
letter, otherwise it would appear along with the answers, which 
are so full of valuable information that we have deemed it 
best to record them without a single change. We take this 
opportunity to publicly thank both Dr. Welch and Dr. Park 
for the many valued suggestions contained therein. 

DR. PARK'S REPLY, 

Buffalo, June 21, 1894. 
Dr. S. Gr. Gant, Ninth and Grand Ave., Kansas City, Mo. 

Dear Doctor: In reply to your favor of the 16th I would say 
that I send herewith one or two papers bearing on the subject of which 
you write, and that I must refer you also to a book published b}^ me two 
years ago, entitled " Mutter Lectures on Surgical Patholog}'," in which 
I have devoted some little space to the matter of intestinal toxemia. 
This book was issued by J. H. Chambers & Co., of St. Louis. I regret 
that I have not a cop} T at hand which I could send you. The subject is 
to me one of very great importance, and I am glad that }~ou are going 
to devote some attention to it in your forthcoming work. 

I have no doubt that the colon bacillus does play an important role 
in diseases of the rectum and colon, but it is difficult to say under just 
what circumstances. In the light of the most recent investigations, it 
occurs to me that perhaps a little too much importance has been assigned 
to it as the sole factor in these troubles, and that many cases in 
which it is prominent are due to reall}- a mixed infection by which the 
virulence of two or three different forms is very much increased. It is, 
however, considered to be identical with the bacillus pyogenes fcstidus, 



284 DISEASES OF THE RECTUM AND ANUS. 

which is a common organism in ninny cases of perirectal abscess. I have 
found them in various abscesses around the colon, higher up, and even on 
the right side, and of these I can say that at the time of opening, at least, 
the pus seemed to be pure culture of this organism. This is not true, 
however, of all cases, by any means, and it may be that in most of them 
some other organism has been present and has died out, for many of them 
are of considerable standing. 

I have also, as reported in one of my papers, found pure cultures 
of colon bacillus in most cases of periappendical abscesses which I have 
thus investigated, and I do think that it is a most active factor in this 
kind of disturbance. I think the circumstances which most co-operate 
to make this organ virulent are the presence of certain putrefactive or- 
ganisms combined with habitual constipation. Mere ulceration or abra- 
sion of the mucosa, by itself, I think may predispose to virulence of effect 
of the organism, but such ulceration is not very likely to be brought about 
by the said causes which tend to make the organism more virulent. 

In reply to your third query as to whether the bacillus can enter 
the circulation through sound membranes, there is every reason to think 
it can. Numerous investigators have found it under many circumstances, 
and I consider it settled that this is possible. 

In reply to the fourth question, I think it is the case that the 
bacillus multiplies more abundantly when the stools are liquid, because 
such a condition furnishes a more suitable culture-medium for it, with a 
more lively distribution, but I really cannot tell which of the two condi- 
tions, diarrhea or constipation, is more likely to cause auto-infection. 

In a general way I think that much depends upon the condition of 
the other eliminatory portions of the system. For instance, if there be 
oliguria, I think extra work is thrown upon the alimentary canal; and 
when to this is added the sluggishness of the skin in many anemic and 
debilitated individuals, I think everything conspires to make the con- 
dition of the intestinal canal worse and more active. I think also much 
depends upon dilatation of the stomach, which is often present, in at 
least more or less degree, and upon the perfection of disposition of the 
stomach-contents. The presence of lactic and of fatty acids has much 
to do, I am sure, with the trouble, and yet I certainly cannot tell you 
just how, nor do I know of any one who can. 

Reasoning from the other direction, I am quite sure one gets valu- 
able suggestions, if not exact knowledge, from the fact that the very best 
treatment, in my estimation, for operation, and especially for abdominal 
operations, consists largely' of careful purging for several days before 
the operation itself. This is with reference not only to the colon bacillus, 
but to all the organisms which inhabit the intestinal canal. If one re- 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 285 

members that the colon bacillus belongs primarily in the intestines, and 
that it is identical with other forms discovered by various observers, to 
which different roles have been assigned, one will get a better idea of the 
possibilities and properties of this organism. I have no doubt there are 
pure types of colon infection which produce peritonitis (this is particu- 
larly the case with append ical trouble), but, as every surgeon knows, these 
cases are not invariably fatal, and many observations conspire to prove 
the benefit of clearing out the alimentary canal when this condition is in 
its incipiency or perhaps merely threatening. 

I shall await the appearance of your forthcoming book with no little 
interest, and shall be very glad if in the slightest degree I have helped to 
call attention to this very important subject. 

Very sincerely jours, 
(Dictosteno.) Roswell Park, 

dr. Welch's reply. 

935 St. Paul St., Baltimore, June 26, 1894. 
S. G. Gant, Esq., M.D., Kansas City, Mo. 

Dear Doctor: My first observation of invasion of internal organs 
of the bod}' by the bacillus coli communis — and, I believe, the first on 
record — was reported by me to the Association of American Physicians 
in 1889, I think. (I have not the reference at hand.) This was in a 
case of multiple fat necrosis associated with diphtheritic colitis. In the 
article referred to by you in the Medical News I gave the conclusion 
reached up to that time. I have no doubt that the colon bacillus is a 
frequent invader of the circulation and internal organs, particularly the 
lungs, kidney, and liver, in cases with lesions of the intestinal mucosa, 
and sometimes without such lesion being demonstrable. In the great 
majority of these cases, in which we are able to demonstrate by culture 
at autopsy the presence of the colon bacillus outside of the intestinal 
tract, there is no evidence that such invasion has produced an}- damage. 
Microscopical sections show colon bacilli often abundantly in the blood- 
A r essels of the kidney, and often in parts without evidence of lesion of 
the surrounding parts. These facts, it seems to me, justify skepticism 
about referring to the colon bacillus as of great importance, as many nowa- 
days do, even when it is present in inflammatory areas. One must con- 
sider whether, in such cases with actual lesion, it may not be a secondary 
invader in parts primarily diseased through some other agency, including 
other micro-organisms. I have, for example, found the colon bacillus in 
tuberculous p} 7 elitis and in gonorrheal pyelitis. The primary micro- 
organism may have died out and the colon bacillus, which is a resistant 
micro-organism, may survive alone and keep up the inflammation. Still 



286 DISEASES OF THE RECTUM AND ANUS. 

there are, of course, observations which leave little doubt that the colon 
bacillus may exert definite pathogenic action. I contend, however, that 
not a few cases recorded in which disease has been attributed to the 
colon bacillus will not stand critical scrutiny in the light of all of the 
facts which are now known. In my paper on "Conditions Underlying 
the Infection of Wounds" ( a Transactions of the Congress of American 
Physicians and Surgeons," vol. ii) I express myself with candor as to 
the pathogenic role of the colon bacillus. I am very skeptical about the 
prevalent view that the colon bacillus is the cause of appendicitis. Being 
a constant inhabitant of the intestine, it, of course, is present in the dis- 
eased as well as the normal appendix, but in the former case, in my 
experience, usually in association with unquestioned pyogenic bacteria. 
The same has been my experience in perforative peritonitis, contrary to 
that of some French and Italian observers. The colon bacillus is so 
widely prevalent, it is so easy to cultivate on all media and at all tem- 
peratures, that I cannot help suspecting that often other bacteria were 
overlooked. 

As regards the relation of the colon bacillus to proctitis and peri- 
proctitis, I doubt very much whether it is capable of causing either of 
these diseases in healthy tissue. It is certainly found with great regu- 
larly in perirectal abscesses, usually, I think, in combination with other 
bacteria of proven pyogenic power, but sometimes in pure culture. In 
the latter case, however, I should suspect previous disease of the part 
from some other agent, although given this primary lesion the colon 
bacillus may be a factor of importance in producing and confirming the 
supposition. 

As regards the general subject of auto-infection from the intestinal 
canal, of course, although the colon bacillus is the most common invader, 
other bacteria may likewise enter through this portal, notably the iso- 
genic micrococci. Definite lesions of the intestinal mucosa here too are 
important predisposing factors, as is illustrated in some cases of second- 
ary infection in dysentery, typhoid fever, etc. As regards the predis- 
posing influence to infection, which may be exerted by absorption of 
toxic substances, products of decomposition, etc., from the intestinal 
canal, it seems to me that we have very little definite information, 
although plenty of speculation. 

The question of invasion of the colon bacillus and its pathogenic 
significance were considered by me in the " Middleton Goldsmith Lect- 
ure " before the Pathological Society of New York at the end of last 
April. The lecture has not been published, but will appear in the New 
York Medical Journal in the course of a couple of months. I must refer 
you to that for a fuller statement of my views on this subject. 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 287 

Hoping that I may have touched upon some of the points on which 

3'ou desired my views, I am, 

Very truly yours, 

William H. Welch. 

This chapter has already reached a length far beyond our 
expectations. For this reason we will at once hasten on to the 
more important part of this subject, — that of treatment. 

Treatment. 

We shall not attempt a detailed discussion of the many 
remedies that have been suggested for the prevention and relief 
of auto-infection of intestinal origin, but will mention only the 
more salient features. 

The treatment in a large measure should be prophylactic, 
and every effort should be put forward to keep the system in 
perfect order and the equilibrium maintained ; so long as this is 
accomplished nature is capable of defending herself against any 
and all toxic substances generated within the body. Any dis- 
ease or symptom of a disease that would predispose a patient to 
auto-intoxication from poisons normally generated within the 
body must be eradicated at once. As we look at it, there are 
three essential features that must be constantly borne in mind 
in the treatment of auto-infection. 

1. We must remedy any condition which predisposes the 
patient to self-infection. 

2. We must use every possible means to prevent the abnor- 
mal production and absorption of poisons within the intestinal 
canal. 

3. We must do all we can to assist nature to neutralize 
and eliminate poisons already absorbed. 

To accomplish the first we must correct any condition that 
will cause an erosion or that weakens the mucous membrane in 
any way, because it prepares the way for the entrance into the 
circulation of toxic substances within the intestine. Hence we 
must correct irritative discharges of all kinds: we must heal 



288 DISPOSES OF THE RECTUM AND ANUS. 

ulcers and fissures ; we must remove hemorrhoids, polypi, and 
other growths. In fact, we must first get rid of any local disease 
of the rectum and colon present, or all our efforts directed 
toward the prevention and relief of auto-infection will be of no 
avail. 

There are some cases in which we can find no local cause ; 
then we must look elsewhere, and in all probability the exciting 
cause of the infection will be found to be either a diarrhea or 
constipation and fecal impaction. When due to either, we 
would recommend a line of treatment previously laid down in 
the chapters devoted to these subjects. Whenever there is an 
irritant within the intestinal canal that promotes auto-infection, 
the safest plan is to give a vigorous cathartic, one of the mer- 
curial if you choose, which will cause it to be expelled. Then 
we must institute a laxative tonic treatment, to be continued for 
a long or a short period, dependent upon the extent and con- 
tinuation of the infection. Very often poisonous substances can 
be eliminated from the system by the constant and abundant 
use of reputable mineral waters known to have a cathartic 
action. Sometimes it will be necessary, in addition, to adminis- 
ter a pill composed of aloin, strychnine, and belladonna, which 
lias stood the test of time, or one composed of the lactate of 
iron, extract of nux vomica, and purified aloes given three times 
a day. Perhaps the most striking example of the importance 
of cleansing the intestinal canal is to be observed after abdomi- 
nal operations. All of us have seen the temperature of our 
patients suddenly rise two or three days after an operation. 
The wound being healthy, we are nonplused to account for 
the disturbance. We finally decide to give a cathartic, the 
bowel is cleansed of accumulated feces, and immediately the 
temperature becomes normal. In the treatment of auto-infec- 
tion it is necessary to correct errors in diet, prohibit the use 
of alcoholic stimulants, and have our patients take only such 
foods as they can digest easily. If we were going to recom- 
mend any special diet we should select milk, for experience 



AUTO-INFECTION FROM THE INTESTINAL CANAL. 289 

has proven that it is opposed to all sources of intoxication and 
puts a check upon auto-infection due to intestinal putrefaction. 
We now turn our attention to the second feature in the 
treatment, and endeavor to prevent the abnormal production 
and absorption of poisons. To accomplish this we must resort 
to the intestinal antiseptics, both local and systemic. Perhaps 
the best general antiseptics, either alone or in combination, are 
the iodides of potash and sodium. We have many times wit- 
nessed beneficial results from the continued use of these drugs 
in cases where the system was saturated with poisons. There 
are many medicines that are highly commended as intestinal 
antiseptics, such as iodine, creasote, benzoic acid, boric acid, 
salol, resorcin, turpentine, the mercurials, etc. Many of the 
above-named antiseptics undergo changes in their course through 
the alimentary canal, ere they reach the colon, which diminishes 
their activity. The best results are usually obtained from those 
insoluble drugs which remain unchanged throughout their 
course, such as salicylate of bismuth, salol, iodoform, and naph- 
thalin. When the salicylic acid accumulates in the blood and 
threatens complications, the subnitrate of bismuth may be sub- 
stituted for the salicylate. In giving these intestinal antiseptics 
it is not necessary that the dose should be sufficiently large to 
kill the bacteria, but large enough to render them dormant, as 
it were, thereby preventing their multiplication. We know of 
nothing better than the subnitrate of bismuth in combination 
with charcoal to neutralize poisons already formed and to pre- 
vent fermentation and putrefaction. We make up a powder 
containing ten grains of each, to be repeated at short intervals 
until there is evidence of relief, such as a diminution of tender- 
ness over the abdomen and of tympanites. The bismuth seems 
to prevent the putrefactive fermentation, while the charcoal 
diminishes the toxins. Iodoform may be combined with char- 
coal or with naphthalin to accomplish the same purpose. To 
diminish the fecal odor as well as its toxicity, Bouchard com- 
bines seventy-five grains of naphthalin with an equal amount 



290 DISEASES OF THE RECTUM AND ANUS. 

of sugar made aromatic with one or two drops of bergamot. 
This mixture he divides into twenty powders and gives one 
every hour. In this way he claims putrefactions within the 
intestinal tube may be completely suppressed. 

The last feature in the treatment consists in assisting 
nature to neutralize and eliminate poisons which have already 
entered the circulation. To accomplish this we must see that 
the eliminatory apparatus is in perfect order, for when any one 
of the emunctories gets out of order poisons immediately accu- 
mulate in such quantities that nature can neither neutralize nor 
eliminate them. The blood must be toned up by tonics, if 
necessary, the liver and the kidneys by medicines that will 
stimulate them to renewed activity, and the skin must be kept 
in order by frequent cold baths, followed by a brisk toweling. 
In addition to remedies directed for the perfection of the emunc- 
tories, we must see that patients suffering from auto-infection 
lead a simple, regular, active, occupied life, and do not mope 
about and brood over their afflictions. 

BIBLIOGRAPHY 
of the books and papers consulted in the preparation of this chapter : — 

1. Verclen, J. E., Indianapolis: "Auto-Infection from the Intes- 
tinal Canal," Indiana Medical Journal, July, 1893. 

2. Hickman, J. W., Tacoma, Wash.: "Auto-Infection," Medical 
Sentinel. 

3. Sternberg, G. M., Washington, D. C. : "The Bacteriology of 
Pyelonephritis," American Journal of Medical Sciences, June, 1894. 

4. Keys, Edward L., New York City: "Nephritis in its Surgical 
Aspects," American Journal of Medical Sciences, June, 1894. 

5. Park, Roswell, Buffalo, N. Y. : " The Importance to the Surgeon 
of Familiarit}' with the Bacillus Coli Communis," Annals of Surgery, 
September, 1893. 

6. Welch, William H., Baltimore, Md. : "Conditions Underlying 
the Infection of Wounds." Transactions of the Congress of American 
Physicians and Surgeons, vol. ii. 

7. Bouchard, Ch., Auto-Intoxication in Disease. The F. A. Davis 
Company, 1894. 

8. Park, Roswell, Lectures on Surgical Pathology. J. H. Cham- 
bers & Company, St. Louis, 1892. 



CHAPTER XXVI. 

CANCER OF THE RECTUM: ITS ETIOLOGY, SYMPTOMS, 
VARIETIES, AND TREATMENT. 



By Herbert William Allingham, F.R.C.S.Eng. 



A careful consideration of the experiences of other sur- 
geons, together with my own study in the hospital and private 
practice, has left me without any definite opinion as to the 
causes of cancer of the rectum. Opinions are so different, 
statistics are so contradictory, either in statement of fact or in 
argument therefrom, that it is impossible to state any dogmatic 
views as to the etiology of cancer in this portion of the body. 

It may be and sometimes is hereditary, but even as to this 
statistics and surgeons disagree. Some surgeons strongly aver 
that it is hereditary, but many pages have been devoted to show 
the very small proportion of hereditary instances in private 
case-books or hospital records. There are very few families in 
which it has not occurred, but fewer still in which the parents 
or grandparents of the patients have any of them suffered from 
the disease. It may run in the family or in the collateral 
branches, as in uncle or aunt, brother or sister, and more 
frequently still in cousins ; but that does not argue transmission 
by heredity in the direct line. Such being the case, all that 
can be safely said is that cancer is a malignant growth which 
may attack the anus, rectum, and other parts of the bowel, and 
thence spread to adjacent organs. When it assails the rectum it 
usually runs its course in about two years, though some patients 
last four months and others linger on for four and a half years. 
It is to be regretted that modern life seems rather to foster- than 
to hinder the disease, for cases of cancer of the rectum are more 
numerous than they were early in the century. Perhaps, how- 

(291) 



292 DISEASES OF THE RECTUM AND ANUS. 

ever, this arises from cases being- more carefully diagnosed and 
more fully enumerated than was formerly the case. The dif- 
ficulty of always distinguishing between malignant and innocent 
growths may have caused the proportion of cancer cases to 
appear somewhat larger at the present day, but we must 
remember the fallibility of the microscope and the danger of 
pronouncing one piece of growth innocent when its neighbors 
are malignant. 

All j^riods of life are liable to cancer of the rectum, 
although it is said sometimes to be peculiarly common to middle 
age. We have met boys aged 17 and 13 years afflicted by the 
malady. Old people too are sometimes attacked, but they are 
usually subject to the slower forms and live long, for then the 
vital forces are sluggish. Women have been believed to be 
more subject to cancer than men ; this may be true of the body 
as a whole, taking into account the liability of the breast and 
the uterus ; but for the rectum and the large intestine statistics 
show that many more men than women are attacked by cancer. 
The records of St. Mark's hospital for two years show five- 
sevenths of male to two-sevenths of female rectal cancer cases. 
In the early stages some forms of cancer may be simply and 
purely local ; but this stage is exceedingly brief, and the tem- 
porary local nature is scarcely true of the more malignant forms, 
— that is to say, as soon as a growth is so developed as to be 
noticed by the patient, the disease is constitutional in most cases. 

After mentioning the cluneal varieties of cancer of the 
rectum and bowels, we can collect the various opinions of 
pathologists and microscopists on the processes of the forma- 
tion and growth of cancer. Not much, that is certain, will 
be stated, but students and operators may be able, the one 
to learn, the others to compare their own experiences. After 
this the sharply-marked kinds will be described, which alone 
are of* practical importance to the surgeon. 

According to the old nomenclature the various forms of 
malignant disease were termed epithelioma, scirrhus, several 



CANCER OF THE RECTUM. 293 

kinds of sarcoma, — encephaloid, colloid, and melanoma, — but 
later investigations have resolved many of them under the head 
of adenocarcinoma, Mr. Cripps having devoted much micro- 
scopical study in his researches with these varieties. Indeed, 
the three forms — scirrhous, medullary, and colloid — are the 
varying conditions of one growth or a portion of that growth. 
This adenocarcinoma has by other writers (I refer to my late 
colleagues, Mr. Alfred Cooper and Mr. Swinford Edwards) been 
divided under three heads, — the laminar, the tuberous, and the 
annular. The laminar form is the most common and the intes- 
tinal wall is infiltrated or thickened, the thickening occurring 
between the muscular and the mucous coats and spreading 
laterally. The surface of the growth gives way after a time, 
and leaves behind a ragged ulcer. The disease usually begins 
in the centre and eats its way outward. Sometimes the deposit 
is only partially destroyed by the ulceration, and its remains 
form tumors which enter the cavity of the bowels. At other 
times the coats of the bowels are destroyed and the neighboring 
organs are perforated. 

In the tuberous form the growth projects into the bowels. 
The mucous membrane is soon destroyed by the ulceration, and 
some of the growth projects through the opening thus made. 
The cancer has outgrowths and attacks the neighboring tissues 
and structure. 

In the annular form the growth commences as a deposit 
between the mucous and muscular coats and ascends laterally, 
finally entering the entire circumference of the bowel. Hence, 
by subsequent contraction the calibre of the bowel is reduced 
and severe stricture is caused. 

Cancer of the rectum may also be classed under five heads, 
which include several distinctive features : — 

1. There is a variety like a growth, often the size of a five- 
shilling piece, situated at the lower part of the rectum. To the 
feel it appears to have a pedicle, but in reality that sensation 
arises from its dragging upon the mucous membrane. 



294 DISEASES OF THE RECTUM AND ANUS. 

2. The second variety resembles the first in its position, 
thus showing that it is not a growth out of the bowel, but an 
ulcer or depression surrounded by irregular, nodular edges. It 
is movable and as large as the first. It is generally confined 
to the lower part of the rectum, and healthy gut can be felt 
above it. 

3. A third kind is to be found in the lower inches of the 
rectum. Indeed, it combines the peculiarities of the two 
previous kinds ; all around the gut there are irregular nodules 
interspersed in the area of depressed ulcerations. It is not fixed 
to the deeper structures and is therefore movable. 

4. The fourth kind is found higher up in the bowel and is 
a hard growth combined with ulcerations. It both involves the 
gut and inclines to the surrounding tissues. It is, therefore, 
rarely at all movable. Its starting-point is about three inches 
up in the rectum, but its upper limit is not easy to discover. 

5. A fifth variety begins even higher up in the bowel — say, 
about four or five inches (10 or 12 centimetres) — and is, as 
a rule, a very hard growth which involves the circumference 
of the bowel. It is extremely movable and intussuscepts into 
the lower part of the rectum. Its feel resembles that of the 
neck and mouth of the uterus in the vagina. 

Symptoms. 
The many and various symptoms of malignant diseases of 
the rectum are of supreme importance to the surgeon in making 
his diagnosis, and a wide experience has shown that some of 
them are practically certain signs of cancer. Such is the icaxen 
aspect of the countenance, which appears in cancer of the 
rectum even earlier than it does in malignant diseases in other 
parts. But it must be remarked that in some patients the 
appearances of vigorous health are maintained until the malady 
is already in full activity. Another sure sign is the peculiar 
odor, which the experienced cannot fail to recognize; this is 
essentially indicative of cancer. Very slight disorders mark the 



CANCER OF THE RECTUM. 295 

beginnings of the disease. — viz.. uneasiness in the bowel or 
slight morning diarrhea. The patient goes to stool frequently 
and passes jelly-like excretions, which are not true matters, but 
are merely the mucus and other matter passing from the growth. 
Another symptom is that it is difficult to pass matter without a 
motion following. The pain arising from cancer of the rectum 
is, as a rule, most intense and is enhanced by the daily functions 
of that part, but sometimes in the early stages the pain is not 
very severe. In the more advanced stages the suffering is 
often unremitting, for many nerves are involved by the growth 
and are pressed upon or stretched ; thus the neighboring 
organs become seats of separate pain, though they may not be 
actually touched by the growth. One patient had a cancer 
which, commencing in the rectum, involved the whole cavity of 
the pelvis and caused most severe pain down the right sciatic 
nerve. Violent straining is one of the most distressing symp- 
toms. The cancerous mass, especially when nearing the anus, 
provokes reflex action and causes irresistible bearing down. 
When the surgeon turns to tactile examination the feel of can- 
cer to the finger is pathognomonic and cannot be mistaken by 
the practiced surgeon for simple ulceration. For the diagnosis 
of rectal cancer the microscope cannot be entirely depended 
upon any more than it can for malignant growths in other parts 
of the body, as the larynx; for, as has been often remarked, the 
portion of the growth removed and examined may be innocent, 
while the neighboring portions may be emphatically malignant. 
The symptoms and position having been noted and a correct 
diagnosis having been arrived at, the point is the proper treat- 
ment to pursue, whether for the alleviation of pain or for the 
saving of life. 

Treatment. 

Palliative. — It must be understood that palliative treat- 
ment is to be employed only in cases where removal by ex- 
cision is quite out of the question or in those cases not yet 
sufficiently bad to require colotomy. The protrusion of a 



296 DISEASES OF THE RECTUM AND ANUS. 

cancerous mass (which is somewhat of a rarity) may be usually 
stopped and the pain relieved by the application of arsenite of 
copper villi mucilage as a paste. There is no hemorrhage or 
danger whatsoever. In most cases the palliative treatment can 
merely be devoted to the alleviation of pain, — viz., recumbent 
posture^ food easily digested, nourishing diet, with a moderate 
amount of alcohol. All sorts of sedatives may be beneficially 
employed, either externally or internally, and when one ceases 
to be of service another may be tried instead. Opium in one or 
other of its forms is the best ; if applied as a suppository the 
most effective formula is morphia with glycerin and gelatin 
(three parts of glycerin to one of gelatin), for this melts speed- 
ily and feels less like a foreign body than suppositories of coca- 
butter. Suitable injections are Battley's sedative and nepenthe, 
or black drop, in starch. Much good is done by solid opium 
by the mouth, but the stomach becomes irritated, there is a loss 
of appetite, and the bowels are confined. Hypodermatic injec- 
tion of morphine gives much comfort, but the mental state 
caused by the constant use of morphine becomes almost as un- 
bearable as the cancerous pain itself, and I am strongly of the 
opinion that the greatest care should be taken to administer no 
larger closes than are absolutely necessary, for the treatment, to 
be effective, may have to be continued for months. Mr. John 
Clay, of Birmingham, used to advocate the use of Chian turpen- 
tine, but it has been found to be of little service. In very few 
cases were the symptoms mitigated, and in the rest the effects 
were nausea and frequent derangement of the appetite and the 
functions of the stomach. Such treatment failing, mild opera- 
live mcas/tres are the best to be resorted to. Division of the 
sphincter muscle is of service when the growth approaches the 
anus, for the defection is made easier and there is no possibility 
of compression as noted above. Cancer of the upper part of 
the rectum, through its pressure on the nerves, inhibits the 
action of the sphincter and prevents patients from retaining the 
motions, especially if they are at all liquid. For diminution of 



CANCER OF THE RECTUM. 297 

the calibre of the bowel, Professor Verneuil used to advise 
free division of the gut in the dor so-median line, I have found 
this of service, but do not recommend his alternative proposal of 
excision of a segment of the posterior wall of the rectum. In 
encephaloid of the rectum much temporary advantage is gained 
and great mitigation of the pain procured by tearing out the 
growth with the fingers or a scoop, the fingers being preferable. 
Boldness is necessary, and the whole growth must be torn from 
its nucleus quickly and resolutely. If only superficial portions 
are torn away, the patient may have an exhausting hemorrhage 
and will receive no benefit. I have found this plan of much 
avail in cases where colotomy was not advisable, but only be- 
cause no great loss of blood need be caused. Sometimes when 
the growth has been hard I have taken it away with a Volk- 
mann spoon. This is of advantage when the growth is within 
reach, for the scooping away allows the passage of the motions, 
and with patients who have objected to colotomy I have, by 
this means, prevented total obstruction. The methods to 
alleviate the pain from cancer of the rectum and to stave off 
death, perhaps (?) to cure the disease itself, are excisions of the 
desired portion and one or other of the forms of colotomy. I 
will reserve the subject of colotomy for another chapter, and 
will now turn to excision of the rectum. 

Excision of the Rectum. — It is not my intention to enter 
into the operation of excision of the rectum, or to describe 
the various ways in which it may be performed ; but the 
reader who wishes the fullest information on these subjects 
may be referred to the able and exhaustive work of Dr. Mar- 
chand, entitled "Etude sur l'extirpation de l'extremite inferi- 
eur du Rectum." I will onlv here mention that Fas;et, in the 
year 1739, excised the rectum for cancer, that after this the 
operation remained in abeyance until 1828, when it was revived 
by Lisfranc, who performed it in several cases with success. At 
a comparatively recent date it has been frequently undertaken 
by both French and German surgeons, and with such good 



298 DISEASES OF THE RECTUM AND ANUS. 

results as to establish the operation on a reliable basis. The 
Americans and ourselves have brought up the rear; possibly 
we are more cautious and have had our doubts as to the great 
benefits claimed for it by our foreign confreres. Certainly we 
are justified in distrusting such statements as that of Dieffen- 
bach, who said he had thirty cases of successful extirpation of 
the rectum, the patients living many years after the operation. 
We have also felt incredulous as to the advantage derived from 
cutting out the rectum, a portion of the urethra, prostate gland, 
and base of the bladder, as did Nussbaum, who gravely assures 
us that the patient recovered all his functions and lived for 
three years. Lately a method has been suggested in which the 
rectum may be excised from a posterior incision combined with 
the usual ones. Excision of the rectum (as it is frequently 
termed), broadly speaking, may be undertaken in any form of 
cancer which does not necessitate the removal of more than 
four and three-fourths or five inches (12 or 12.7 centimetres) of 
the rectum in the male and about one inch (2.54 centimetres) 
less in the female. Subject to the results of increased experi- 
ence, I should also say that if great adhesions are formed to 
the sacrum or to the base of the bladder and prostate gland, or 
to the neck of the uterus in women, the operation is probably 
not admissible, and certainly not desirable. Again, if any en- 
larged glands exist in the inguinal or lumbar regions the oper- 
ation cannot be recommended. Lastly, the patient ought not 
to be so exhausted as to render it doubtful whether the neces- 
sarily rather free loss of blood would, to a great degree, endanger 
life. 

The first condition is the patient's age. 1. In those under 
40 years of age the prognosis as regards recurrence after ex- 
cision is bad, for the growths, being very rapid and of an infil- 
trating nature, are likely to return soon or recur in the excision 
wound before it has even healed. 2. Between the ages of 40 
and 60 the cancer is less common and of less rapid recurrence 
after excision, but still that period of life is not wholly favorable 



CANCER OF THE RECTUM. 299 

as regards early recurrence. 3. For patients above 60 excision 
is advantageous and the after-results are satisfactory, for the 
growth is, as a rule, hard and retractiug and has slighter tend- 
encies to recurrence. 

In the varieties of cancer described on pages 293 and 294 
as 1, 2, and 3, when the upper limit of the growth or ulcer- 
ation can be reached and it is movable, excision is advisable ; but 
if the growth is at all adherent the disease will certainly recur 
rapidly, more especially so the younger the patient is. There- 
fore, in young subjects and those about 40, excision should not 
be performed. In suitable cases the excision should be very 
free and, when possible, the whole of the circumference of the 
rectum should not be removed, for, if a piece of the gut can be 
left, it prevents the troublesome after-contraction which occurs 
when the whole circumference of the bowel is removed. In 
variety 4 excision is altogether out of the question, for, as the 
growth does not begin until several inches above the anus, the 
operation is necessarily very severe, and, as the growth is some- 
what fixed, it is difficult to insure its complete removal. In 
variety 5, if the patient is willing and thoroughly understands 
the danger of the operation, inguinal colotomy should first be 
performed and followed later by Kraske's method of excision. 

In doubtful cases the following points should be the 
surgeon's guide : The amount of adhesion to the deep structures 
should be taken into consideration. If the growth is situated 
near to the prostate or bladder, excision should not be done ; 
but with a dorsal situation of cancer the operation may be 
attempted. The method of entire excision formerly employed 
by me was that which has found most favor with the French 
authorities. The deep dorsal incision I really consider the 
" key " to the operation. It gives plenty of room, which is 
essential if one has to remove any considerable length of the 
rectum, and so get fully above the growth. Further, it saves 
much loss of blood, as it enables one to secure the vessels, 
if necessary, with rapidity and certainty. Lastly, it forms a 



300 DISEASES OF THE RECTUM AND ANUS. 

deep drain or channel through which all obnoxious matters can 
freely escape. It is the retention of morbific particles which is 
dangerous ; let them all run away as they are generated, and 
we may defy pyemia without any antiseptics. In saying this I 
am not insensible to the advantage of these chemicals when one 
cannot get deep drainage. In operating on the male always 
have a silver catheter passed into the bladder; the assistant 
hooks it well up under the pubic arch ; the urethra and ad- 
joining parts are thus steadied, and it is possible to carry on 
delicate dissections without danger in the neighborhood of the 
urethra, the prostate, and the trigone of the bladder. By the 
following method the rectum is most easily and rapidly excised: 
The patient being in the lithotomy position, a modification of 
the posterior dorsal incision of Prof. Verneuil should be made. 
The usual way is, on the ringer to pass a bistoury into the 
rectum as far as the upper limit of the growth, and then to cut 
right down into the sacrum and tip of the coccyx, dividing the 
entire bowel dorsally. The first finger of the left hand is then 
put into the bowel and a sharp-pointed bistoury is introduced 
through the skin a little below the anus, making it travel in the 
cellular tissue up to the top of the growth, but entirely outside 
of the rectal tube. Then cut down to the sacrum and coccyx, 
and put a sponge into the incision to arrest bleeding. (See Fig. 
79.) Next, with a scalpel cut deeply all around the rectum, 
above the external sphincter attached to the skin. Then divide 
the external sphincter posteriorly. Do this when it is possible; 
i.e., when the growth does not come too low down. Now, with 
the finger in the rectum and the thumb in the cut between the 
sphincters, put one blade of a pair of long, blunt-pointed scis- 
sors into the posterior cut and push the other blade into the 
cellular tissue of the ischio-rectal fossa. After this, cut through 
all the cellular tissue between the blades, and repeat this pro- 
ceeding on the other side, keeping the finger of the left hand in 
the rectum while the left side is being incised, and the first 
finger of the right hand while the right side is being cut. Of 



CANCER OF THE RECTI. M. 



301 



course, to manage this properly you must be ambidextrous. 
Then introduce sponges into the incisions on each side of the 
bowel and separate the outer parts from the bowel by broad, fiat 
retractors. (See Fig. 80.) Bleeding is then prevented and 
you need not stop to clip the vessels. Next, turn to the perineal 
part. With the finger still in the bowel and the thumb outside 
it you can tell, by the amount of the wall of the gut between 
finger and thumb, how near to the rectum you are cutting. If 
the scissors is kept cutting on the thumb-nail, and the rectum is 
drawn backward while you are cutting (see Fig. 81), there is 




Fig. 79.— Herbert Allingluun's Method of Excision of Rectum. 



no danger of wounding the urethra or bladder, or of incising 

the bowel. When all the rectum is separated from the tissues 
around to one inch ('2.54 centimetres) or more above the growth, 
the sponges may be taken out. On to the rectum, now freed, 
above the growth apply a large pair of Spencer Wells's 
rectangular pressure-forceps, one on one side and one on the 
other side of the gut. When the rectum is removed on the 
distal side of the clips a stout ligature is passed beyond the 
rectangular part of the clip and is tightly tied as the clip is 
slowly slackened. The same is done with the other clip. This 
secures any large superior hemorrhoidal vessel that there may 



302 



DISEASES OF THE RECTUM AND ANUS. 



be in the eut end of the gut. There is generally little bleed- 
ing, because the inferior hemorrhoidal vessels and any others 
running across the ischio-rectal spaces of the rectum are small, 
and soon retract and contract. They may be easily made to do 
so by sponging the wound with equal parts of very hot water 
and spirit. The only large vessels that may be divided are the 
superior hemorrhoidal, which are situated in the rectal walls. 
It is well, before cutting the lower part off, to secure the upper 
part with the clip, as it might otherwise slip out of reach and 
bleed freely. By these means the rectum may be removed in 




Fig. 80.— Herbert Allingham's Method of Excision of Rectum. 

ten minutes with the greatest ease. There are a few important 
points to be observed in this method of excision : — 

1. Little hemorrhage is to be feared if the above details 
are attended to, and, the more quickly you operate, the less 
bleeding there is. If an hour be taken in excising the rectum 
much blood is necessarily lost by your wasting time to pick up 
vessels which will stop bleeding of their own accord if left alone 
or subjected to a little pressure. 

2. By not dividing the bowel itself when making the 
dorsal incision you can, by means of the finger in the gut, 
which is still a tube, and by the thumb, which is outside the 



CANCER OF THE RECTUM. 



303 



rectal wall, easily tell where you are cutting. Greater speed is 
thus insured. 

3. By leaving the external sphincter, when it is possible, in 
the outer skin, sphincter power is retained after the operation, 
whereas if the external sphincter is removed with the gut no 
retentive control can be exercised. Several patients upon whom 
I have operated in this manner have had good control over 
their motions. 

4. Blunt-pointed scissors are used in the greater part of 




Fig. 81.— Herbert Allingham's Method of Excision of Rectum. 

the operation, as one can cut with them with more precision 
and greater rapidity. 

5. In women the assistant's finger ought to be introduced 
into the vagina to give timely warning when you approach too 
near its mucous membrane. 

In most of my cases it was absolutely impossible to bring 
down the stump of the rectum to the skin ; if, indeed, these 
parts could be brought together the tension would be so great 
that the sutures would be torn out in a few hours. It is hard 
to understand how Volkmann brings the rectum to the skin, 
puts in sutures, and gets primary union. 



304 DISEASES OF THE RECTUM AND ANUS. 

I have never used carbolic dressings with the view of fol- 
lowing Sir Joseph Lister in his antiseptic treatment ; in fact, 
these operations appear to me to be about the very last to which 
the process, valuable as it undoubtedly is in some cases, is ap- 
plicable. Looking at the chasm I make and the part in which 
it is made, to shut up the cavity by sutures and then endeavor 
to keep that cavity sweet and healthy by drainage-tubes and 
deeper tubes put through holes made by the surgeon would be 
making a plaything of antiseptic surgery. How can one pre- 
vent fecal matter from getting into the wound, so incompletely 
closed as it must be by sutures % Perhaps it may be said that 
the bowels must be kept confined for days after the operation. 
To this the answer is that it is often impossible to do so. The 
intestines of these patients are always in an irritable condition, 
and neither opium nor any other drug will delay action for 
long. Then, again, it is not good to confine the bowels, for, 
should a large mass form in the upper part of the rectum, such 
pressure on the vessels is exerted that congestion and stasis are 
induced, and these conditions are quite inimical to the healing 
process. The best after-treatment of these cases is to establish 
a good drainage from the wound and to keep the parts clean by 
syringing with some disinfectant ; and if you accomplish this 
you need not fear, for the wound will rapidly fill up and the 
rectum will grow downward and unite with the skin. 

A modification of excision which has been freely discussed 
of late years is Kraske's method, which has found some favor 
with German surgeons and has itself been modified in detail. 
I have used it on several occasions. With the patient placed on 
his side, an incision is made in the median line through the soft 
parts of the back, extending from the second sacral vertebra to 
the anus. The muscular attachments to the sacrum are then 
divided as far as the edge of the bone on the left side. The 
coccyx is next excised, the sacro-sciatic ligaments are divided 
as near as possible to the sacrum itself, and the left edge of the 
wound is drawn aside. By chiseling away the lower part of 



CANCER OF THE RECTUM. 305 

the left side of the sacrum easier access is obtained to the upper 
part of the rectum. Thus additional room is made by dividing 
the bone in a line starting on the left edge at the level of the 
third posterior sacral foramen and passing in a curve concave to 
the left, through the lower border. The chisel is next turned 
through the fourth foramen to the lower corner of the sacrum 
on the left. The rectum is then in sight and can be excised up 
to its junction with the sigmoid flexure. Further, if desirable, 
the upper part of the rectum can be excised, the lower portion 
being left intact. 

Dr. Rehn, of Frankfort, begins his modification by an 
osteoplastic resection on the left side of the sacrum. An incision 
is made, and the bone is divided transversely between the third 
and fourth foramina, the flap of the bone, etc., being put aside 
to the right. Ample room to work in is thus obtained, and the 
surgeon can remove the growth from above and behind. Within 
ten days, if there is still insufficient defecation, the intestine 
may be incised above the stricture. The gut is then pulled 
down and joined to the lower portion. Farther modifications 
have been devised by American surgeons. 

After- Treatment of Excision of the Rectum. — The vessels 
being secured and the parts thoroughly sponged with hot spirit 
and water, the finger is inserted into the end of the bowel, there 
being always sufficient room between the stout ligature put on 
to the stump of the bone above the rectangular Spencer Wells 
clips. A long strip of wool is then passed along the finger into 
the bowel. This prevents any blood escaping into the intes- 
tines should there be any after-hemorrhage. The large cavity 
from which the rectum was removed is then well stuffed with 
some antiseptic wool, and a T-bandage is tightly applied so as 
to exert pressure upon the wool which plugs the cavity. The 
patient, after the operation, suffers, as a rule, some consider- 
able shock, and requires careful attention and administration 
of stimulants. If the shock be very severe it may be advisable 
to transfuse three or four pints of warm saline solution. The 

20 



306 DISEASES OF THE RECTUM AND 1NUS. 

next day the greater part of the wool is removed, the parts 
being kept moist with some antiseptic solution. Day by day 
more of the wool is removed, the piece of the bowel being 
pulled out not later than the fourth day. On this fourth day a 
good dose of castor-oil is given and the bowels are made to act 
freely, and are then kept acting every other day. The wound 
should be dressed gently, night and morning, with iodoform or 
any other ointment which may appear to be suitable for the 
wound^ according to its condition. When, in some weeks' time, 
the parts are mainly healed, the finger must be passed night and 
morning, or, if necessary, a bougie may be inserted and allowed 
to remain in the rectum a few minutes at a time. As a rule, 
after the parts are healed it is necessary for the patient to pass 
the bougie occasionally, — say, every other day or once a week 
for several months. 

Recapitulation. 

It will be gathered from the foregoing pages that I am not 
very strongly in favor of the operation of excision of the rec- 
tum. I have come to this conclusion from the observation of 
the very large number of cases of cancer of the rectum which 
I have seen, and from the results of about seventy cases of 
excision which I have done. It is seldom one sees a really 
favorable case for excision. It is perfectly useless to excise the 
rectum when the growth is high up in the bowel or at all fixed 
to the surrounding deeper parts. Again, I have noticed that 
excision of the rectum, or even of parts of the rectum, in the 
younger subjects, ends — though the case be most favorable for 
the operation — in an early recurrence of the growth. The only 
cases which appear to give any satisfactory results are in old 
subjects, where the local conditions are most favorable to the 
success of the operation. In several cases the patients have 
remained free from any recurrence of the growth for as many 
as ten years. Old people appear to stand the operation very 
well, and it is, therefore, well worth performing when the case 




3" 

P EG 
PJ Pi 



E-h 



fe ^ 




c=> PP 

< ^ 

en pp 
PC % 

PQ ( — ) 

E en 
^ <£! 

PJ Q 

cn t^ 
3< 

<C P=> 
LJ E— 

l-H PJ 

£^ 

CIh CD 



CANCER OF THE RECTUM. 301 

is a suitable one. With regard to the question of partial or 
even complete excision of the rectum, whenever it is possible I 
leave a healthy strip of mucous membrane, for when it is nec- 
essary to excise the entire circumference of the gut it is usually 
followed by most troublesome after-contraction. So bad is this, 
and so much worry does it cause at times, that in some of my 
cases it has been advisable to perform inguinal colotomy and 
allow the rectum to close. This contraction can only be avoided 
by having such a strip of mucous membrane, which acts as an 
elastic splice and allows of easy dilatation. On several occa- 
sions I have combined excision of the rectum with colotomy. 
In some cases I have excised the rectum first, and then followed 
it some weeks later by colotomy, and afterward excised the 
rectum. In the former of these combinations I have, as a rule, 
performed the colotomy because the rectum has shown, during 
the process of healing, such a tendency to troublesome contrac- 
tion. In the second class I have excised the growth subse- 
quent to the colotomy because I found that excision was now 
possible ; whereas, prior to the colotomy, when the growth was 
imbedded by feces, I had not thought excision either possible 
or justifiable. 

Though I have made use of these combinations, I do not 
think, if the growth is likely to recur, it will be hindered from 
so doing by a preliminary or by a subsequent colotomy. 

In spite of all my plain speaking with regard to excisions, 
I should like it to be borne in mind that, if there is any ques- 
tion as to the innocence or malignancy of the growth, it should 
be jDvesumed to be innocent, and, therefore, not be excised, even 
though it be extensive. 



CHAPTER XXVII. 
COLOTOMY. 



By Hekbert William Allingham, F.R.C.S.Eng. 



I intend to set forth as plainly as possible the advantages 
and the disadvantages of colotomy as a whole ; to show the 
good points or the demerits of the main forms of colotomy, — 
namely, left lumbar, right lumbar, left inguinal, right inguinal, 
and transverse, — and to indicate when each one of these respect- 
ive operations can be employed with the most beneficial results. 
It has been thought wise to enumerate all these five methods, 
but for the next few pages, and, indeed, during the greater part 
of the chapter, left inguinal and left lumbar colotomy will form 
the main topic of discussion. The transverse method will be 
described in its place ; but as it is rarely used, it cannot yet be 
said to compete in importance with the inguinal and lumbar 
modes. 

No doubt there may be a tendency for the advocates of 
the inguinal method slightly to urge its advantages over the 
lumbar mode, but I am confident they would not assert that 
lumbar colotomy should never be resorted to. In this they do 
not follow the example of those veteran surgeons who confine 
themselves to praise of the older method, and who altogether 
ignore the advantages of inguinal colotomy, an operation which, 
according to their own writings, they have rarely or never per- 
formed. Inguinal and lnmbar colotomy alike would suffer from 
such biased opinions, and some surgeons might be dissuaded 
from trying both operations, and would thus be unable to judge 
which was the better to perform in the different circumstances 
arising in the course of their practice. 
(308) 



COLOTOMY. 309 

Now that inguinal eolotomy has been fairly and freely 
tried, we are in a position justly to compare it with the lumbar 
method. An endeavor may be made to assign to the two 
operations their due rank in surgery, and to insure their em- 
ployment on the most fitting occasions. If this attempt be 
successful, the full value of each operation will be brought out, 
and we shall desist from that old plan of using always the one 
or always the other, under which in certain conditions the 
method neglected was safe and proper, and the mode actually 
employed was dangerous and wrong. 

These remarks as to the injuriousness of bias with regard 
to any particular form of eolotomy apply as strongly to the old 
prejudice against the operation in general. Formerly eolotomy 
was regarded as an extreme measure, which was only to be 
employed in cases where the patient was nearly bursting from 
distension. It was considered to be dangerous and rash, though 
the danger resulted mainly from faulty modes of operating and 
from the slighter attention to antiseptic precautions than is paid 
nowadays. The making of an artificial anus was held to be a 
nauseating device, and I have heard medical men tell their 
patients that they themselves would rather die in the utmost 
agony than have colotomv done to them. Such remarks are 
positively wicked and absurd, and probably proceed from men 
who have rarely seen the operation performed, and who know 
nothing of the suffering which it saves and the relief which it 
gives. Views of this kind must have been handed clown by 
tradition from professional ancestors, who were as ignorant as 
the present holders of such opinions. Men of this stamp 
cherished the same antipathy to ovariotomy in the early days 
of that operation, and deterred their patients from undergoing 
it. But such futile prejudices have been swept away by the 
energy and ardor of later surgeons, and the old notions against 
colotomv are sharing the same fate. 

A survival of these ideas is the postponement of eolotomy 
to the last possible moment. But we have now come to see 



310 DISEASES OF THE RECTUM AND ANTTS. 

that it is our duty not only to snatch patients from a distressful 
death, but also to relieve pain and discomfort in the earlier 
stages of their maladies, so that their remaining days may be 
made as peaceable as possible, and that death, when it does 
arrive, may come to pass with comparative ease. 

I trust I shall not be charged with saying that every patient 
with cancer, or with ulceration combined with stricture, is, as 
soon as he is seen, when the malady is in an early stage, to 
undergo colotomy there and then. That would be as false and 
harmful treatment as to put off operating till obstruction had 
almost caused death. Such cases should be carefully treated by 
opiates, etc., and should be attentively watched. As soon as it 
is found that the patient is beginning to suffer from incessant 
diarrhea, from profuse bleeding, or from great pain, which cannot 
be remedied by medicine, we may then fairly ask whether life 
cannot be made less wretched, and whether colotomy is not best 
suited for that purpose. 

When the patient is in such a state of suffering his med- 
ical attendant should explain to him how matters really stand. 
If he be a victim of cancer he should be told that he has an 
incurable disease which will grow, and that he may expect an 
increase of his discomfort, whether it be persistent diarrhea, 
bleeding, or pain. He may then be informed that his trouble 
will probably be relieved by colotomy ; but he must also be 
made to understand what colotomy means, — viz., that the mo- 
tions will always pass by the artificial opening. All questions 
asked should be faithfully answered, and the medical adviser 
should state what choice he would make and what he would 
have done to him if he were placed in similar circumstances. 
Strongly to urge colotomy without fully explaining its meaning 
is obviously as wrong and unfair as the prejudiced advice not 
to undergo colotomy. Inveterate habit and ingrained ignorance 
may still sometimes prevent the performance of colotomy when 
it is really needed, but its advantages are constantly becoming 
more generally recognized. A careful consideration of the 



COLOTOMT. 311 

condition of the patient is the first requisite, and then, when we 
have put away all preconceived notions, we shall be able to see 
whether colotomy is advisable or not, and shall be able to deter- 
mine what method is best adapted to the particular case. 

The Conditions Necessitating Colotomy, and the 
Choice of Operation. 

We must now consider what are the conditions which call 
for one or other of the operations of colotomy, — namely, left 
inguinal, left lumbar, transverse, right lumbar, or right inguinal. 
I have already described the various kinds of cancer in the rec- 
tum, but it is necessary to state the position it may occupy in 
the other parts of the large intestine. In the sigmoid, descend- 
ing, transverse, and ascending colons cancer is generally an 
annular, scirrhus-like growth, which gives rise to narrowing of 
the gut. Occasionally in any one of these positions the disease 
may be an extension of a cancer in one of the neighboring 
organs, which, by its growth, pressure, or contractions, may 
narrow the colon in any of its segments. Putting aside the 
rectum, the most common places for these annular strictures 
and pressure-growths are at the sigmoid, splenic, and hepatic 
flexures, the order given representing the degree of frequency. 

Narrowing of the gut may also follow from tubercular 
ulceration, syphilitic ulceration, or dysenteric scars or ulcers, 
with stricture. In the sigmoid flexure there may be traumatic 
or inflammatory conditions due to pressure upon the sigmoid 
intestine by the child's head during labor, or to adhesions or 
contractions which result from neighboring inflammation or 
abscesses. It is obvious that inflammations or contractions in 
the vicinity may similarly cause inflammatory conditions in any 
part of the colon. Last of all, there may be some congenital 
narrowing of the gut, necessitating colotomy either in early or 
in later life. But these states are rare and need not occupy 
space in this work. 

The question at once arises: When is colotomy called for'? 



312 DISEASES OF THE RECTUM AND ANUS. 

The commencement of obstruction is the first point to be 
discussed. When the rectum is involved and an obstruction is 
felt and begins to be complete it is needless to waste time by 
waiting. The administration of oil, injections, and so forth, 
is of no practical use, for they give but temporary relief, and 
the patient will be sure to have to undergo the operation later 
on, probably under much more adverse circumstances, when he 
is worn out and exhausted by distension. In such rectal cases, 
therefore, it is far better to perform colotomy as soon as the first 
definite symptoms of obstruction become manifest. 

In other parts of the large intestine it is not wise to per- 
form colotomy immediately, for there is no absolute certainty as 
to the nature of the obstruction, which may be only fecal, and 
its position is often very difficult to diagnose. In these cases, 
then, abstinence from solid food, administration of belladonna, 
etc., should be first tried, and if they fail to give relief colot- 
omy may be resorted to. If the first attack of obstruction is re- 
lieved, and its nature and position are doubtful, colotomy should 
not be done till after repeated attacks of slight obstruction. 

A few words further as to the seat of the obstruction. 
When the growth or stricture is situated within the rectum it 
can be felt, and a rapid decision can be made as to the time for 
performing colotomy ; and if the stricture be innocent it can be 
determined what other line of treatment is best to pursue, — e.g., 
the use of bougies, division, and so forth. But when the ob- 
struction is in any other part of the large gut, unless a mass 
can be felt, it is extremely difficult to tell what portion of the 
intestine is affected. It is then that, from fear of performing 
colotomy too early, it is advisable for the surgeon to wait until 
fairly definite symptoms are manifested of an obstruction which 
cannot be relieved by drugs. 

Pain is the next topic of importance. 

Some of the cancers of the rectum give intense pain, for 
the motions may pass over an angry, ulcerated surface, or into 
a crater-like mass in which a portion of them may become 



COLOTOMY. 313 

lodged. When the motions pass over the growth they incite a 
strong desire constantly to go to stool, and the incessant strain- 
ing gives rise to pain. Here colotomy is wanted to allay such 
suffering. 

Cases of ulceration with stricture of the rectum are fre- 
quently combined with very large and extensive fistulas, which 
spread from the ulceration in the rectum out into the buttocks. 
These fistulas are often very numerous, and when feces and 
flatus pass through them the pain is extremely severe. For the 
relief of this, and for the prolongation of a life which may be 
made better worth living, colotomy is demanded. 

When proceeding from annular cancerous strictures in 
other parts of the colon, pain presents great variability. In 
some cases there is little or none till obstruction has become 
almost complete. In other instances it may be frequent, of a 
colicky nature, and spasmodic. The patient may then be able 
to state with approximate accuracy where the pain is, and thus 
lead the surgeon to discover the seat of the obstruction and the 
most appropriate mode of colotomy. 

Sometimes the upper parts of the colon are attacked by 
ulceration with its accompanying contraction, and many inches 
of the intestine are involved. The pain resembles that given 
by cancerous stricture, being often colicky, and occurring re- 
peatedly, but it is not usually severe till obstruction, too, has 
become a marked symptom. Thus the two conditions become 
united, and conjointly require operation. I must observe that 
for pain alone in the higher parts of the colon colotomy is 
seldom needed. 

Bleeding is another state that may necessitate considera- 
tion. This is especially the case with a soft growth in the 
rectum, which is very vascular, and may be torn by the con- 
stant passage of feces over it. The resulting hemorrhage may 
then be very severe and dangerous, and if injections of astrin- 
gents have failed colotomy may be necessary to save life. 
Bleeding rarely occurs to any alarming extent with tubercular, 



314 DISEASES OF THE RECTUM AND ANUS. 

syphilitic, or dysenteric ulcerations, and in these conditions 
seldom calls for operative interference. 

The last state which may warrant colotomy is diarrhea. 
This is notably the case when there is cancer of the lower part 
of the sigmoid flexure and upper part of the rectum, or when 
there is syphilitic or tubercular ulceration not only of the lower, 
but also of the upper, parts of the large intestine. This diarrhea 
may be most intense, and may occur as frequently as twenty 
times a day, greatly distressing the patient, making his life ab- 
solutely miserable, and wearing him to death. When ulcera- 
tions from tuberculosis, dysentery, or syphilis cannot be treated 
successfully by mild remedies, colotomy, by cutting off the 
passage of the feces, allows the ulcerations to heal ; and by the 
immediate stoppage of the incessant diarrhea, the patients are 
restored to a better state of health. Of course, in order to bring 
this about, the colotomy must be well above the diseased portion 
of the gut. 

It must be borne in mind that though we have considered all 
these conditions separately, as a matter of fact they are generally 
combined, and then more urgently call for colotomy. Cancer 
or stricture of the rectum or colon often demands colotomy 
when obstruction is the only symptom ; but there are cases when 
this obstruction is the smallest symptom, and when the patient 
with cancer of the rectum is far more seriously troubled in other 
ways, — viz., he is in constant pain from motions passing over 
the growth, he has great tenesmus, he is terribly distressed by 
having to go to stool over and over again, night and day, and, 
further, he incessantly passes blood mixed with slime. This 
combination of symptoms may occur in cases of cancer or of 
syphilitic or tubercular ulceration in the higher parts of the 
colon ; but, as a rule, obstruction is the main symptom when 
the disease is in the upper part of the gut, and these conditions 
of pain, bleeding, and diarrhea are not so well marked. 

Colotomy is even more necessary in tubercular or syphilitic 
conditions, when mild treatment has failed and the patients are 



COLOTOMY. 315 

running down-hill, than it is in cases of cancer. Cancer is a 
mortal disease, and the sufferer's term of life will not be long. 
These other conditions are not necessarily fatal, and, if the dis- 
tressing symptoms are relieved and the passage of feces is cut 
off, the rest from pain and irritation may allow the diseased 
parts to heal and the patient be enabled to live to a good age. 
The older school may dispute these views in consequence of 
their opinions as to the conditions of existence after colotomy 
has been performed, but I strongly hold to my contention. 

The Choice of Operation. 

We are now led to consider which kind of colotomy is the 
best to perform in any particular circumstances. This question 
of the choice of the operation is of extreme importance. 

First, let us take the cases when the obstruction is in the 
rectum and can be easily felt and diagnosed. These can be 
arranged under several heads. 

1. Cases of very complete obstruction. The obstruction 
having been complete, perhaps, for ten or more days, the in- 
testines are very distended and it is necessary to open the gut 
at once. Cases of this class are, I think, better treated by lum- 
bar colotomy ; for it is only when the intestine is very distended 
that it is possible or probable that the gut can be opened with- 
out opening the peritoneum. My reasons for this assertion 
will be explained when I discuss the lumbar operation. 

2. In the second division the obstruction is well marked 
and of a few days' duration, and the distension, though not 
very great, may at the same time be fairly marked. In this 
class the choice between inguinal and lumbar colotomy may be 
left to the operator, for there is no great necessity to open the 
bowel at once. It is better for the gut to be fixed up (say, for 
twelve hours) till the peritoneal cavity is well blocked off by 
lymph, and thus made safe from extravasation of feces when 
the bowel is opened. If the distension is very slight the in- 
guinal operation should always be chosen ; but if it is well 



316 DISEASES OF THE RECTUM AND ANUS. 

marked and the case borders on class 1, lumbar colotomy should 
be performed. 

3. The third variety comprises those cases in which there 
is very slight or no obstruction, and when the object of surgical 
interference is to relieve pain, irritation, or bleeding, or to di- 
minish the rapidity of the growth. There is no doubt that 
inguinal colotomy is then the better method to employ. 

If the surgeon like, he can perform inguinal colotomy in 
all the foregoing conditions if he will use a Paul tube, which 
may be inserted at once into the distended gut and tied. The 
motion is then carried away by the tube into a basin under the 
bed. In this way chance of the peritoneal cavity becoming 
fouled by feces is prevented. 

The question of choice is further affected by the cause for 
the operation. If it is cancer which gives rise to obstruction 
only, with no pain and little diarrhea, the surgeon is free to 
make his own option between inguinal and lumbar. But if 
the cancer cause great pain, diarrhea, and bleeding, then, if 
possible, inguinal colotomy should be done ; for a good spur 
can, as a rule, be procured, whereas in lumbar colotomy the 
making of a spur is much more a matter of difficulty, and is 
sometimes quite impracticable. When in the rectum there are 
non-malignant strictures, combined with tubercular, syphilitic, 
or dysenteric ulcerations, and often with fistulas, the importance 
and possibility of making a spur again demand inguinal colot- 
omy. 

There are other reasons for preferring inguinal to lumbar 
colotomy. The opening is in front and can be attended to by 
the patient himself with far greater facility than when it is in 
the lumbar region. Further, a pad or truss can be readily 
adjusted to the opening in the groin. The inguinal operation 
can be performed with much greater ease; the patients usually 
get well much more quickly, and there is less risk of opening 
any other viscus than the colon. In all these points the ingui- 
nal is an advance upon the lumbar operation. 



COLOTOMY. 317 

The three remaining forms of colotomy — transverse, right 
lumbar, and right inguinal — are very difficult to choose be- 
tween. Of course, if there is a stricture the position of which 
can be diagnosed, or if, in cases of ulceration, the end or, 
rather, the starting-point of the ulceration can be told, then the 
rule is to perform the colotomy only just above the seat of that 
stricture, or of that stricture with ulceration. But this can 
only be discovered when there is a tumor or distension, or 
when the patient, from the pain and so forth, can indicate the 
locality. 

On the other hand, if the case is uncertain, it is always 
wise to start with a median abdominal exploration. The ex- 
ploratory incision should be made above the umbilicus and the 
hand be passed into the abdomen and down to the sigmoid 
flexure. It should next be traced upward until the stricture is 
felt or the narrowing caused by the ulceration be found to cease. 
The colotomy should then be performed just above the seat of 
the obstruction. For instance, if the disease is about the splenic 
flexure of the colon, choose a transverse colotomy; if it is at or 
extend up to the hepatic flexure, use a right lumbar colotomy ; 
if it extend lower down, resort to the right inguinal operation. 

Again, if an exploratory examination by the median in- 
cision fail to discover definitely where the ulceration ends or 
where the stricture is seated in the large intestine, it is wiser to 
do a right inguinal colotomy, so as to make sure of being well 
above the diseased part. 

Choose the operation which can be done nearest to the 
disease, — that is to say, if the splenic flexure be at fault, use 
transverse colotomy. The reason is that the length of the 
transverse mesentery gives a good chance of making a splendid 
spur ; but this opportunity is not always found in right lumbar 
and never occurs in right inguinal colotomy. 

There is another good reason for colotomizing as near the 
rectum as possible; the higher one proceeds in the bowel, the 
less solid the feces become. In left inguinal and in left lumbar 



31 S DISEASES OF THE RECTUM AND ANUS. 

colotomy it seems that the feces are nearly solid, for the greater 
part of the large intestine is above them and absorbs their 
liquid portion. In the transverse operation the motions are 
generally, though not invariably, liquid. In the right lumbar 
and the right inguinal methods, as far as my experience goes, 
the feces are always liquid, and are a continual source of annoy- 
ance to the patient later on, for motions are retained when 
solid, but are constantly discharged when liquid. 

It is perhaps advisable to add that when the median ex- 
ploratory incision has been made and transverse colotomy is 
decided upon, the lower part of the incision is brought together, 
the upper inch (2.54 centimetres) or so alone being utilized to 
bring the transverse colon through, and then fixed up into the 
wound. If the examination reveal the impossibility of a trans- 
verse colotomy, or of one lower down, — i.e., nearer the rectum, 
— the incision is closed, and a right lumbar or right inguinal 
operation is proceeded with in the manner hereafter to be 
described. 

Anatomy of the Colotomies. 

Before describing the various methods of performing colot- 
omy it may be well to devote a little time to the anatomy of the 
regions to be operated on. Minute details are useless from a 
surgeon's point of view ; but, at the same time, rough surgical 
anatomy may be found to be of assistance when any difficulties 
arise in the operations. 

Left Inguinal and Eight Inguinal Colotomy. 
"We will first discuss the anatomy of left inguinal and 
right inguinal colotomy, for the main features are alike, the 
only differences lying in the character of the gut and the varia- 
tions in the arrangement of the peritoneum. The skin need 
not detain us, but the cellular tissue varies greatly, sometimes 
being very thick and extensive, especially in stout patients, 
whereas in the thin there may be little or none whatever. The 
next structure of importance is the external oblique muscle, 



COLOTOMT. 319 

whose fibres run in the direction of the superficial incision, — 
viz.. downward and inward. Its thickness, of course, varies 
with the muscular development of the patient. As soon as 
this muscle is divided, the internal oblique is exposed, and may 
be recognized by the direction of the fibres. — viz.. upward and 
inward. The next object of interest is the last layer of muscle, 
the transversalis abdominis, which may be distinguished by the 
transverse direction of its fibres, which run from outward 
directly inward. When this has been exposed and divided, a 
thin layer of fascia comes to view, which is known as the trans- 
versalis fascia, and varies both in thickness and in color. If 
the operator is not careful this may be mistaken for the perito- 
neum, and much time be wasted over it under that erroneous 
impression. Under this lies the subserous areolar tissue, which 
may present another pitfall ; for it is often taken to be the 
omentum. This is more especially the case when the trans- 
versalis fascia has been opened in the belief that it is the peri- 
toneum. This error, however, should never occur, for the fat 
of the subserous areolar tissue is very different from the fat of 
the omentum. It is usually darker in color and more consistent, 
and never bulges up through the opening in the transversalis 
fascia as the omentum does when the peritoneum is opened ; 
for. when that is the case, the omentum, if near, bulges through 
and even appears, as it were, to flow through the aperture in the 
peritoneum. 

After the subperitoneal fat has been divided the peritoneum 
is reached. It is of a slatish-blue hue. and is as variable in 
thickness as most of the other structures already described. 
The peritoneum, as is well known, lines the posterior surface 
of the belly-muscles, and as it approaches the side of the bellv 
is reflected from these muscles over the surface of the sigmoid 
colon, then over the iliac fascia and iliacus muscle, which 
occupy the concave anterior surface of the ilium. It is impor- 
tant to bear this in mind in connection with the two errors just 
referred to ; for when the transversalis fascia has been mistaken 



320 DISEASES OF THE RECTUM AND ANUS. 

for the peritoneum, and the subserous areolar tissue has been 
thought to be the omentum, and been burrowed about in, the 
peritoneum which covers the subserous areolar tissue may be 
pushed off the ilium and the search for the gut made over the 
surface of the ilium, the peritoneal cavity having never been 
opened at all. 

Another important point in connection with the perito- 
neum is the way in which it surrounds the sigmoid flexure. 

As shown in Fig. 82, the peritoneum lines the abdominal 
muscles and then passes over the sigmoid, binding it closely 
down to the ilium (there being little or no play for the gut; in 
fact, there being little or no mesentery) and then being refiexed 
over the surface of the ilium. 



Fig. 82.— Relations of Peritoneum with Mesentery. 

Fig. 83 represents the second state, when, in consequence 
of the reflexion of the peritoneum, there is some movement of 
the intestine. Here there is what I would term a medium-sized 
mesentery. In Fig. 84 there is a long mesentery, and thus there 
is free movement of the sigmoid flexure. 

These three conditions only hold to any large extent in left 
inguinal colotomy, though at times, but rarely, they may apply 
to the cecum. As a rule, however, Fig. 82 represents the state 
of the cecum. Though apparently trivial matters, these points 
are of great importance from the surgeon's point of view, both 
with regard to operating and to the after welfare and comfort 
of the patient. 



COLOTOMY. 



321 



Lumbar Colotomy. 

The regional anatomy of lumbar colotomy presents many 
affinities to that of inguinal colotomy, though there are differ- 
ences. In the lumbar region the cellular tissue is usually more 
abundant. The first muscles divided are the external oblique 
and the latissimus dorsi, which are in the same plane. As 
in inguinal colotomy, the fibres of the external oblique run 
downward and inward, and behind this is the latissimus 
dorsi, the course of its fibres being directed downward. This 
muscle (as is the case in all regions) is separated by a 
thin layer of cellular tissue from the internal oblique, whose 
fibres go upward and inward, the posterior ones running 
almost directly upward. The next structure is the lumbar fascia, 

Abd. wall. — ~_^_^ Abd. wall. 

Peritoneum. ^*^\ Peritoneum. 

— Gut. . \.\.— Gut. 

Medium •' ^^^^^ * "~.".":l...l.... I^ong 
,*"N I Mesentery. vlll iP '/ *• I Mesentery. 

/ 

Fig. 83. Fig. 84. 

Relations of Peritoneum with Mesentery. 

which, if the term be permitted, is the tendon of the trans- 
versalis muscle, a few of the posterior fibres of which may be 
exposed as it springs from the fascia. These fibres have a trans- 
verse direction. This fascia is very tough and thick, and is 
usually of a strong, fibrous nature. When the transversalis 
muscle and its tendon are divided, the anterior edge of the 
quadratus lumborum may be exposed, or may have to be severed, 
if it is large. The fibres of this muscle run vertically upward 
or incline slightly upward and backward. Nearly on the same 
plane as the quadratus lumborum, and under or posterior to the 
transversalis abdominis, is the transversalis fascia, which is inti- 
mately blended with the fat which is below or behind it, and in 

21 





3'2'2 DISEASES OF THE RECTUM AND ANUS. 

which, or rather among which, the kidney and colon are to be 
found. In the lumbar region the subserous areolar tissue is 
very thick and abundant, and at times is difficult to distinguish 
from the peritoneum which it covers. 

The next structure to be exposed is the posterior or outer 
surface of the large intestine, and then, as used to be said, with' 
ont opening the peritoneum, there appear the longitudinal bands 
and appendices epiploic® 

Xow, in order to explain when the longitudinal bands can 
really be seen, and when they cannot, it is necessary to give a 
detailed description of the large intestine. I am compelled to 

AM. wall. 
Peritoneum. 

-\ v ..\.„. / Appendices 

ML- — , 

i 
i 

,1./. — \Epiploicae. 
Fig. 85. — Longitudinal Bands and Appendices Epiplo'icae. 

do this, for it has been stated that, in lumbar colotomy, when 
the parietal peritoneum is not opened the longitudinal bands and 
the appendices can be seen, and that thus the large intestine can 
be distinguished from any other part of the intestinal tract. 

We are aware that the large gut, from the cecum down- 
ward, has two distinctive features. The first is the presence of 
the three longitudinal bands, one on the anterior surface of the 
gut, Fig. 85 (A), another on the posterior (B), and the third on 
the inner aspect (C). The second characteristic is that attached 
to the large gut are the appendices epiploicae, which occur on no 
other part of the alimentary canal. I have noticed that the 
peritoneum, as it is reflected from the anterior abdominal mus- 




COLOTOMY. 323 

cles, is loose, and that then, where it commences to surround the 
large gut, it becomes quite firmly adherent to the intestine at 
the longitudinal band A, It is now so fixed that it cannot be 
separated from the gut, it covers up band C, and is continued 
on to band B. Finally, from the posterior edge of B it may 
pass off the gut on to the posterior part of the abdominal wall. 
Thus Fig. Sd will show that the outer part of the gut is un- 
covered by peritoneum. However, I have already explained 
that this is by no means the usual state of things. If we look 
at the cases of a medium-sized mesentery (as in Fig. 83), we see 
that the peritoneum is continued even farther backward beyond 
and behind the bands A and B (Fig. 85), and thus forms a 
mesentery, and that hence little or none of the intestine is un- 
covered by peritoneum. In cases where there is a long mes- 
entery (Fig. 84) this is even more marked, for then there is 
practically no part of the gut uncovered by peritoneum. 

There is another important point which further disposes of 
the erroneous idea that the longitudinal bands can be seen with- 
out the parietal peritoneum being opened. Take a piece of 
large intestine covered by its peritoneum and carefully examine 
it. It will then be observed that when the intestine is sur- 
rounded by peritoneum the bands are most distinct, looking 
like white, silvery lines, about a quarter of an inch (6.3 milli- 
metres) broad. All three of them will usually be found to be 
well marked. But when examination is made of a piece of large 
intestine uncovered by peritoneum, no band is visible. Further, 
if an attempt be made to strip the peritoneum off the intestine 
at A and B, the longitudinal bands will be seen to come away 
with the peritoneum and then become lost ; or, if they do re- 
main attached to the gut after the peritoneum has been removed, 
they are most indistinct and badly marked. 

The above will show how mistaken are those who hold 
that the longitudinal bands, as bright, shiny bands, can be seen 
without opening the parietal peritoneum. Probably, unknown 
to themselves, they have divided the peritoneum and so opened 



324 



DISEASES OF THE RECTUM AND ANUS. 



the abdominal cavity, for unless that cavity is opened it is 
impossible to see the bands on the large intestine. 

I contest in the same manner the assertion that the appen- 
dices epiploicse can be seen without opening the peritoneum. 
This, again, is an impossibility. These appendices are but 
small pedunculated masses of fat, enveloped by peritoneum 
(see Fig. 85) and attached to the inner aspect of the intestine. 
The diagram shows that to view them it is absolutely necessary 




Fig. 89. Fig. 91. 

State of Gut with Varying Mesenteries. 



to open the parietal peritoneum. To see them on the non- 
peritoneal surface of the intestine would be impossible, for if 
not covered by peritoneum they would lose their distinctive 
characters and become small masses of fat, indistinguishable 
from the subserous areolar fat, which has to be worked through 
in the downward progress to find the gut. 

There is a further point, — the anatomical arrangement of 
the peritoneum when the gut is distended or collapsed. When, 



COLOTOMY. 325 

as in diagram 86, there is a distended gut, with little or no 
mesentery, the peritoneal reflexions are separated, and hence a 
good portion of the posterior or outer aspect is uncovered hy 
peritoneum. Less surface is uncovered when, as in diagram 
87, the gut is undktended. These alterations are of practical 
importance only when there is no mesentery, for when there is 
a medium mesentery, as in 88 (distended gut) and 89 (undis- 
tended gut), or a long one, as in 90 (distended gut) and 91 
(collapsed gut), there is no separation to be seen which is of 
real surgical value. 

Transverse Colotomy. 

Transverse colotomy, as already observed, is usually com- 
bined with an exploratory abdominal section, the incision made 
being a median abdominal one. The anatomy is as follows : 
After the skin has been divided some cellular tissue is met with, 
which varies in amount, and a few small vessels, w 7 hich gener- 
ally require attention. The next structure which is seen is the 
median raphe, and a little to the left of this may be observed 
the aponeurosis of the internal oblique; this covers the next 
object for consideration, — viz., the rectus abdominis, whose 
fibres run in a perpendicular direction from above downward. 
These fibres are divided, and w 7 e come upon the posterior layer 
of the fascia of the internal oblique ; this, too, is divided, so as 
to expose the subserous areolar tissue and, lastly, the perito- 
neum. The transverse colon is now reached, and can be identi- 
fied from its longitudinal bands and appendices epiploicoe. It 
has a good mesentery, w 7 hich is easily to be made out. Obvi- 
ously, if the large omentum present, it may have to be pushed 
out of the way before the colon is arrived at. 

In this sketch of the anatomy of the region I have de- 
scribed the anterior and posterior layers of the divided tendon 
of the internal oblique,, with the rectus abdominis between 
them. Hence, it will be noticed that the incision is taken 
through the rectus muscle, and not through the central point of 



o2G DISEASES OF THE RECTUM AND ANUS. 

union in the middle line, for at that spot there are no layers of 
the tendon of the internal oblique and no rectus muscle is 
divided. However, I have purposely gone through the rectus, 
for it is the best incision, as it leaves a far firmer scar than 
when the incision is made in the median line. The latter 
is the usual place, but it is wrongly chosen, for a weak scar is 
often left, which may lead to hernia in the future. 

If a division be made of the right rectus, the round liga- 
ment of the liver may be seen after the posterior sheath of the 
rectus has been cut ; but it is not advisable that the incision 
should ever be made except slightly to the left of the middle 
line. 

The Operation of Inguinal Colotomy. 

We now arrive at the operation of inguinal colotomy. 
Though the right inguinal mode will receive brief mention, the 
discussion will be mainly of left inguinal colotomy, which is by 
far the most frequently performed. 

Whenever there is any possibility of choice as regards the 
anesthetic, it is better to use chloroform, — not that it is safer 
than ether, but because it presents several advantages from an 
operative point of view. When under ether, patients are in- 
vigorated, but in chloroform anesthesia they are, as a rule, 
rather depressed and therefore quieter. Thus their breathing is 
less rapid, and, when the operation is being done, the abdominal 
muscles do not move so much. Further, chloroform causes a 
greater relaxation of the muscles and renders them easier to 
work in, whereas ether appears to stimulate them. If there be 
this stimulation, the fingers, when inserted in the abdomen, are 
gripped by the muscles and cannot he used so freely. 

Again, with chloroform there is never, or seldom, the 
straining which is noticed while patients are under ether. This 
straining, or coughing, naturally tends, when the abdomen is 
opened, to force its contents through the aperture, and, more- 
over, makes the muscles rigid. Sometimes, too, the stimulation 
of ether causes bleeding from small arteries and veins, in conse- 



COLOTOMY. 327 

quence of the congestion which is occasioned. This does not 
occur when chloroform is used, for it lowers the arterial tension. 
Attention to these details may render the operation easy and 
comfortahle, while a disregard of them may make it difficult and 
irritating. 

The instruments are as few and as simple as possible, — viz., 
a small scalpel, about half a dozen of Spencer Wells's clips, a 
pair of dissec ting-forceps, scissors, and straight needles. 

The patient is placed on a hard couch and anesthetized, 
the legs and chest well covered with blankets, a mackintosh 
being over these, and wet towels over the mackintosh. The 
part — viz., the left or right inguinal region — is well cleansed 
and cleared of any hair. 

Then, about one and one-half inches (3.8 centimetres) in- 
side the left anterior superior spine of the ilium, and parallel 
with Poupart's ligament, divide the skin and cellular tissue by 
an incision not more than two inches (5 centimetres) long, and 
frequently less. With a stroke of the knife sever the external 
oblique and the other muscles until the subserous areolar tissue 
is reached. This is picked up with two clip-forceps and divided. 
As soon as the peritoneum is opened (which may. as a rule, be 
told from some omentum forcing its way through the aperture), 
introduce the finger into the opening, and with scissors divide 
the deep structures up to the extent of the skin-wound. I never 
use a director, which is a confusing instrument, and tends fre- 
quently to split up the structures into layers. If the operator 
has a keen eye and a light hand, all the structures down to the 
peritoneum may be divided with rapidity and certainty, and all 
such perplexity be avoided. As soon as the peritoneum is 
divided secure it with clip-forceps so as to prevent it being- 
pushed away ; moreover, when it is held up. it stops any oozing 
of blood from the cut muscles passing into the abdomen. A 
flat sponge, with a string attached (to prevent it being lost in 
the belly), is introduced to keep the intestines out of the way 
and to catch any blood that might drain into the abdomen, 



328 DISEASES OF THE RECTUM AND ANUS. 

while the parietal peritoneum is being carefully sewn to the skin 
all round by interrupted tine carbolized silk or catgut. This 
mode of joining the skin and the peritoneum induces rapid 
healing and lessens the danger of discharge from the muscles 
rinding its way into the peritoneal cavity. 

Then the sponge is removed and a search is made for the 
sigmoid flexure. In most cases it bulges into the wound, and 
is easily recognized by the longitudinal bands and appendices 
epiploicse, but occasionally the small intestine or the great 
omentum presents itself. When the large intestine does not 
appear, pass the first finger into the abdomen, sliding it over the 
iliacus muscle until you arrive at the intestine, which should be 
hooked up to the opening with the finger and thumb. If this 




Fig. 92.— Suturing Gut. 

maneuvre fail, search toward the sacrum, feel for the rectum, 
and trace the gut up ; should this not succeed, the finger must 
be passed upward toward the kidney and the descending colon 
felt and traced downward. This usually has to be done when 
the mesentery is long, — say, 5 inches (12.7 centimetres) or more. 
The large intestine is much thicker and firmer to the feel than 
the small intestine, and can be distinguished from it by the 
ridges formed by the longitudinal bands. 

When the gut has been found and brought to the surface, 
pass it through the fingers and seek for a piece with a sufficient 
mesentery. Naturally this can be done only when the seat of 
the disease is in the rectum or the lower part of the sigmoid 



COLOTOMY. 



329 



flexure. Generally the part of the sigmoid first pulled up has 
quite sufficient mesentery. 

A good knuckle of gut being pulled through the wound 
with the finger and thumb, the mesentery is made out behind 
the intestine. A needle threaded with carbolized silk is next 
passed through the skin on the outer edge of the abdominal 
opening, then through the mesentery behind the bowel, back 
again through the mesentery, and is then tied to the end which 
had previously gone through the skin. (See Fig. 92.) When 
the suture is tightened it keeps the peritoneum of the mesentery 
against the parietal peritoneum. This is the safest and quickest 
of the many ways suggested for fixing the mesentery, and is as 




Fig. 93. —Gut After Operation. 



efficient as any of them. The harelip-pin, the use of which 
has been proposed, is clumsy and unnecessary ; further, if it has 
to be removed the mesentery may drop back. Next secure the 
prominent piece of gut to the edges of the wound. In several 
places around fix the gut to the skin by passing the needle very 
carefully, so as not to prick the mucous coat, the sutures being- 
passed only through the muscular and serous coats. If possible 
choose a longitudinal band to put the needle through, for that 
part of the intestine is tough and thicker. Pass one suture at 
the upper and one at the lower angle of the wound, and another 
on the opposite side to the mesenteric stitch, and put in more 
if you find that there is too great a gap between the bowel and 



330 



DISEASES OF THE RECTUM AND ANUS. 



the skin-edge in other parts. The more distended the helly is, 
the more of these sutures are required in order to prevent the 
small intestine or the omentum from being forced out between 
the large intestine and the skin-wound. 

By this method I have often performed the operation in 
fifteen minutes. When the operation is finished, the appearance 
of the gut is as shown in Fig. 93. 

The gut is then covered over by some green protective, 
antiseptic dressings are applied, pads are placed over the opening 
to prevent any vomiting from causing the gut to break away 
from the suture, and the whole is held by an ovariotomy 
baiidage. 

The next day, or even after six hours, if there is great dis- 




Fig. 94.— Removal of Gat. 

tension or much pain, the gut, which by that time is thoroughly 
glued up to the abdominal opening, may be opened, and wind 
and feces be allowed to pass out. If the condition of the 
patient is satisfactory the gut may be left alone for three or four 
days. To open the gut use scissors, cutting the intestine from 
above downward to the extent of about one and one-half inches 
(3.8 centimetres). 

There is generally a large quantity of gut, or rather walls 
of gut, on both sides of the incision. It is now my practice to 
cut tli is away till the edge of the gut is nearly on a level with 
the skin (see Fig. 94) ; the portion above the dotted line in the 
figure is removed. Unless this is done there is too great a 
prominence, for though the walls shrink to a certain extent 



COLOTOMY. 



331 



they do not contract sufficiently. There is little bleeding, and 
no pain is caused when the gut is opened or cut away. If 
there is a good spur a double-barreled opening is now seen. 
(Figs. 95 and 96.) 

The essential point of my operation is to make a good spur 




Fig. 95.— Double-Barreled Opening. 



so as to prevent feces passing below the artificial opening. Here 
is the method in brief: To procure a spur means to fix up the 
gut, by the mesenteric stitch, in such a manner that no feces 
can possibly pass from the upper part of the intestines beyond 





Fig. 96.— Showing Double-Barreled Opening with Directors Passed into Each Orifice. 

the inguinal opening into the portion of the gut below the 
opening ; such passage of feces will only further irritate the 
malignant growth or stricture with ulceration. 

Unless such a spur has been obtained, I consider the oper- 
ation to have been a failure. This is particularly the case at 



332 DISEASES OF THE RECTUM AND ANUS. 

the present time, when inguinal colotomy is done much earlier 
than formerly, and when one of the main objects of the oper- 
ation is to relieve or allay this very irritation. If, through the 
neglect to make a spur, this irritation is maintained, or even 
aggravated, and the concomitant diarrhea and pain are not 
stopped, we shall merely have added to the patient's discom- 
fort ; for he will have a fecal fistula in the groin, instead of 
a complete and perfect artificial anus intended to relieve the 
irritation of the rectum below the opening. 

The Supplementary Operation. 

After I had performed eighteen cases of inguinal colotomy 
I became able to observe the various points of the operation. 
I found that there was one condition in which operating in 
the iliac region might be disadvantageous, not to say distressful, 
in its results. In more than six out of the cases I noticed that, 
after the patients had got up and been able to go about, they 
suffered from a large procidentia of the gut through the inguinal 
opening. This naturally occasions great discomfort and neces- 
sitates the use of a strong truss to retain the intestine in its 
place, and whenever the bowels act this procidentia occurs. 
For a long time I pondered over the possible causes of this 
procidentia and could not easily arrive at a satisfactory solu- 
tion. 

My first theory was that an excessive largeness of the 
incision in the abdominal wall had brought about this unlooked- 
for and altogether undesirable effect. In some of my cases, 
therefore, I limited the incision in the abdominal wall to a 
length less than two inches (5 centimetres) and found some 
variability in the results. In one or two cases the procidentia 
was partially obviated ; in others it was as bad as ever. I had, 
then, to come to the conclusion that my theory had been erro- 
neous, and that an increase or a decrease in the size of the 
incision could neither cause nor impede this protrusion of the 
gut. After thinking over the matter, it occurred to me that the 



COLOTOMY. 



333 



procidentia might have some relation to the length of the sig- 
moid mesentery, which is sometimes of considerable dimensions, 
measuring at least four inches (10 centimetres) from the intes- 
tine to its attachment to the ilium. It may be seen, from the 




accompanying figure, that, if the intestine be pulled out only to 
a limited extent, so as to make a spur, but the mesentery at a 
and b be long, whenever the bowels act the lengthy mesentery 
will easily allow the gut to protrude. The resulting state will 




Procidentia. 



be that shown in the next figure, — that is to say, the intestine 
will be procidented until the mesentery at a and b has become 
taut. 

I now perceived what ought to be done in such cases. 



su 



DISEASES OF THE RECTUM AND ANUS. 



After performing the first part of the operation in the usual 
way, — by making an incision two inches (5 centimetres) in 
length, one inch (2.54 centimetres) internal to the anterior 
superior spine of the ilium, the parietal peritoneum being 




Fig. 99.— Mesentery Made Taut. 

stitched to the skin, — I pull out the gut by its lower end until 
no more can be made to protrude, and do the same to the 
upper end. The mesentery is now quite taut and a large 
bunch of intestine, several inches in length, has been drawn 
through the opening, and is allowed to rest upon the abdomen. 




Fig. 100.— Gut Pulled Out to Full Extent. 

This is represented in the above figures. Then pass sutures 
tli rough the mesentery, and several through the muscular and 
serous coats of the bowel, so as to prevent it slipping back. 
The mesentery being perfectly taut, no procidentia is now 

possible. 



COLOTOMY. 



335 



In two or three days after this first operation the gut is 
opened so as to allow of the exit of wind, and in a week or so 
all the gut outside the belly is removed. First of all, apply a 
clamp about a quarter of an inch from the wound and screw 
it up tightly. The clamp should be provided with spikes, as 




Fig. 101.— Herbert Allingham's Colotomy Clamp. 

shown in Fig. 101, and in any case should have a firm and 
good grip. Unless this is seen to, when the intestine is cut off 
the clamp will slip off the stump and serious hemorrhage will 
ensue. My cases testify to the great importance of this pro- 
vision. Then cut off all the portions of gut above the clamp 
(see Fig. 102), allowing the latter to remain firmly fixed for 




Fig. 102.— Removal of Gut with Above Clamp. 



twenty-four hours, — indeed, as long as any slackening of it 
causes bleeding. When it is taken off, no bleeding will occur. 
The amounts of intestine. I removed in my cases measure from 
four to twelve inches (10 centimetres to 3 decimetres), and 



weigh from three to seven ounces. 



336 DISEASES OF THE RECTUM AND ANUS. 

During the progress of one case I had the opportunity 
— thanks to the kindness of Mr. G. R. Turner, of St. George's 
Hospital — of seeing a post-mortem examination on a subject on 
whom lie had performed inguinal colotomy. The patient had 
been operated on soon after the publication of my first paper on 
inguinal colotomy, and had lived for many months. There was 
no procidentia through the inguinal opening, and I was able to 
discover the reason for this. The sigmoid had no mesentery, 
or, at any rate, an extremely short one ; and the intestine was 
found to be resting close upon the iliacus muscle and was not 
movable in the belly. The operation had been a complete suc- 
cess, a perfect spur having been obtained and there being no 
protrusion. Thus, my theory as to the etiology of procidentia 
following upon inguinal colotomy was satisfactorily confirmed. 

I must confess that this supplementary procedure of cutting 
aw r ay so large a quantity of the gut has somewhat increased the 
seriousness of the operation. Nevertheless, the exceeding dis- 
comfort occasioned by this possible procidentia necessitates a 
fair grappling with the circumstances. 

The fact remains that if the original operation has suc- 
ceeded, and the patient's life is likely to be prolonged for some 
considerable time, the descent of the intestine from the inguinal 
opening must be prevented. It should be remembered that the 
presence of a slack and lengthy mesentery is the sine qua non 
of this supplementary procedure. If this long mesentery does 
exist, and no steps be taken to stay this procidentia, patients 
who have been operated on for innocent stricture with ulceration 
of the rectum, probably combined with recto-vaginal or recto- 
vesical fistulas, will be in the following condition : They have 
submitted to a palliative operation which may have been 
entirely successful in its main object, — the relief of obstruction 
of the rectum, — yet the resulting good has been accompanied 
by a resultant evil. Through the new opening in the groin the 
intestine protrudes, and it is a source of constant trouble and 
discomfort. Some patients have told me that, had they been 



COLOTOMY. 337 

aware of this possible sequela, they would never have consented 
to undergo inguinal colotomy. Their life is simply spoilt, and 
they are practically prevented from going about and mixing 
with the world at large in consequence of the constant pro- 
trusion of the mass. In cases of innocent stricture, where the 
patient is likely to have a considerable lease of life, I would 
strongly recommend the adoption of my supplementary pro- 
cedure of entirely removing all of the intestine that can be 
drawn out of the inguinal opening. 

On the other hand, in bad cases of malignant disease, 
when the patient is greatly exhausted and has probably only a 
few months or, perhaps, weeks to live, I do not deem it wise to 
carry out any further operation. Be content with pulling the 
intestine well through the wound, and so make a good spur. 
If procidentia does ensue it will not be of much moment, for 
the patient will be practically confined to the bed or sofa, and 
cannot lead that more or less active life in which his procidentia 
is so extremely discomforting. 

Still, inasmuch as my clamp does away with any risk of 
hemorrhage, I am not afraid to perform the supplementary 
operation in selected cases of cancer. I have altogether treated 
fifteen cases in this manner, with perfect success as regards any 
after-prolapse, and not one patient has died from it. 

A few points in this operation require special mention : — 

1. Pain is experienced when cutting through the mesen- 
tery, but none whatever when cutting through or into the intes- 
tine proper ; it is therefore wise to administer ether when 
removing the protruding portion of intestine. 

2. The clamp for holding the intestine must be spiked and 
have a firm and certain grip. Unless these requisites are pro- 
vided the clamp will slip and cause severe hemorrhage. More- 
over, the clamp should not be applied too close to the wound, 
but should be placed about a quarter of an inch (6.3 milli- 
metres) distant. It should be kept on till no hemorrhage fol- 
lows on any loosening or unscrewing. In one case I used no 



338 DISEASES OF THE RECTUM AND ANUS. 

clamp, and consequently there was considerable bleeding. In 
another case the clamp was not spiked, and therefore slipped; 
the hemorrhage was exceedingly sharp, and caused me much 
trouble. In a third instance I removed the clamp a little too 
soon, and was obliged to clip two bleeding vessels. Unless all 
the above particulars with regard to the clamp be conscien- 
tiously attended to, the great probability of severe hemorrhage 
will enormously increase the danger of this supplementary 
operation, and may, therefore, tend to militate against its 
adoption. 

Important Points in the Operation of Inguinal Colotomy. 

I now discuss some important details with regard to the 
operation of inguinal colotomy, which I observed from my first 
sixty cases. Unfortunately, I have been unable to trace the 
history of my later cases, sixty-five in number ; but I remember 
that I had points noted in the first series which were fully borne 
out by the last sixtj'-five ; for each important point I retain the 
number of cases of the earlier series. 

The Length of the Mesentery. — For purposes of description 
and classification, I divide mesenteries, as before mentioned, 
into long, medium, and short. By long are meant cases in 
which the mesentery connecting the sigmoid with the iliac fossa 
is at least five inches (12.7 centimetres) in length, or even more. 
In such cases there may be some difficulty in finding the gut 
from the inguinal opening, but I myself have never experienced 
any trouble. In twenty of the earlier cases the mesentery was 
long. 

By a medium mesentery is meant one the length of which 
is at least two or three inches (5 or 7.6 centimetres), so that it 
is possible to pull the gut well out of the wound and to make 
a good spur. There were twenty-nine of this class of mesentery. 

By short are designated cases in which there is practically 
no mesentery at all, and it is, therefore, difficult to fix the gut 
to the skin. Of even more importance is the circumstance that 



COLOTOMY. 



339 



there is no possibility whatever of passing a needle behind the 
gut and forming a good spur. Indeed, no spur can be made. 
Thus, the patients are left in a miserable condition, for some of 
the feces pass beyond the opening in the inguinal region 
toward the growth. There were eleven instances of a short 
mesentery. 

The Spur. — The question of the spur has already been 




Fig 103.— Fecal Fistula. 

briefly mentioned, but the matter is so exceedingly important 
that I must be allowed to return to it, and to distinguish clearly 
between a fecal fistula and an artificial anus. 

A fecal fistula is an opening into a piece of gut communi- 
cating with the surface of the body, from which feces issue ; but, 




Fig. 104.— Artificial Anus. 

at the same time, some of the feces pass beyond the fistula into 
the distal portion of the gut. 

An artificial anus is an opening in which all the feces pass 
through the opening on the surface of the body, and none what- 
ever pass into the distal portion of the gut. 

Now, if inguinal colotomy is performed and no definite 
spur is made, feces pass both by the inguinal opening and also 
into the distal portion of the gut. When, however, a spur is 



340 



DISEASES OF THE RECTUM AND ANUS. 



made feces pass through the opening in the groin, and none 
can enter into the distal end of the intestine. Thus any fecal 
irritation of the growth is entirely prevented. 

I have tried to put the matter in a clear light, because some 
surgeons deny the necessity of making a definite spur, and 
therefore, in my opinion, their operations fail in an exceedingly 
important point. 

It will be observed that in 10 out of my 60 cases no spur 
was formed. In my first 3 cases I had not come to appreciate 
the importance of the spur, and therefore did not attempt to 




Fig. 105. — Procidentia from Upper Opening. 

make one — in fact, I did not use the mesenteric stitch. In 7 
of my cases the mesentery was of the short variety and no spur 
was procurable. In these instances the patients' anatomical 
peculiarities were the reason of their suffering discomfort from 
feces occasionally passing per rectum as well as by the inguinal 
opening, and thus causing pain and irritation. 

Prolapse, or Procidentia, from the Inguinal Opening. — This 
may occur either from the upper end of the gut (i.e., of the 
part which is continuous with the descending colon) or from the 
lower end (i.e., of the part leading to and continuous with the 



COLOTOMY. 



341 



rectum). Sometimes, indeed, there may be prolapse from both 
ends at the same time. 

I have previously observed that it is of far more importance 
to prevent this condition when patients are likely to have a 
fairly long lease of life, and it is on that account that I devised 
the supplementary operation already described. 

Now we know (and my own cases lend corroboration) that 
prolapse occurs only when there is a long mesentery, which 
enables the gut to intussuscept through the part of the gut 
which has been fixed, — i.e., sewn up to the belly- wall. 




Fig. 106.— Procidentia from Lower Opening. 

I arrived at this conclusion from noticing that when there 
was a short mesentery there was no prolapse. 

Again, whenever I had performed the supplementary 
operation, — i.e., whenever I had drawn out and removed the 
slack portion of the gut, — there was once more no prolapse. 

To obviate this prolapsed condition Mr. Cripps has advised 
that the gut should be pulled down until it is taut upon the 
upper end, and that all the slack portion should be returned 
into the belly, and that then the gut should be stitched up to 
the skin-wound. Xo doubt this is a good method, for there can 



342 



DISEASES OF THE RECTUM AND ANUS. 



then be no prolapse from the upper part of the gut. Neverthe- 
less, this plan does not prevent prolapse from the lower part of 
the intestine when the mesentery is long. 

However, the suggestion is of much value, and should 
always be carried out in malignant cases when the supple- 
mentary operation is not advisable. 

Lastly, I have seen prolapse occur from both ends at the 
same time, not only in my own cases, but in those of others. 

Prolapse took place in just 16 out of my 60 cases. 




Fig. 107.— Procidentia from Both Openings. 



In 5 out of the 16 from upper end alone. 

In 6 out of the 16 from lower end alone. 

In 5 out of the 16 from upper and lower ends together. 

In all of these cases the mesentery was either long or 
medium in length, though the prolapse did not occur in every 
instance of a medium-sized mesentery. 

Further, prolapse did not take place in any case where the 
supplementary operation had been performed, in spite of the 
great length of the mesentery in a large number of these 
instances. 



COLOTOMY. 348 

Action of the Bowels. — The action of the bowels may take 
place either from the upper or from the lower end of the double- 
barreled opening resulting from my operation. 

The observation of this fact has caused me to alter some 
details of my procedure. My former practice was to pass the 
mesenteric sutures through the skin nearer the lower angle of 
the wound than I do now ; for I thought the purpose of the 
lower opening was to clear out the rectum or allow any retained 
fecal matter or discharge to come up, whereas the upper orifice 
had to be kept patent and large for the new anus. I now pass 
the mesenteric suture through the middle of the wound, for in 
seven cases the gut, when fixed up to the surface, was twisted 
so that the bowels acted through the lower opening, the upper 
one being continuous with the rectum. In most of these cases 
the mesentery was long ; in others it was reported to have been 
medium, but it may have been in reality long and have been 
rendered of medium length by the twist. There is much danger 
in this twisting if the gut is divided and the lower end is fixed 
up in the belief that it is the upper end. 

Right Inguinal Colotomy. 

Right inguinal colotomy may be performed in the same 
way and by the same incision as on the left side ; but at times 
it is wiser to make the incision lower down and nearer to 
Poupart's ligament. The cecum, or the lowest part of the 
ascending colon, is the region to be opened. All difficulties 
may be met by the details previously explained. The question 
of a spur can never arise. 

It is in this operation where the cecum is very distended 
that Paul's tube is of great value. The peritoneal cavity being 
opened, the cecum is drawn into the wound and incised, a small 
tube being instantly inserted and the cecum tied around it. 
On to the free end of the glass tube a drainage-tube is attached 
which carries the feces into some vessel far away from the 
wound. A few extra stitches are then inserted to fix the cecum 



344 DISEASES OF THE RECTUM AND ANUS. 

to the edge of the wound. In a few days, when the cecum is 
well glued up to the surface, Paul's tube can be removed. 

Operation of Lumbar Colotomy. 

By attention to certain rules lumbar colotomy will not be 
found to be very difficult, but the not uncommon occurrence of 
accidents forces me to think that all surgeons are not sufficiently 
alive to the use of considerable precision in the operation, more 
especially when the bowel is undistended. This indispensable 
element of precision is often lacking in the directions given in 
surgical books on the subject. 

Many surgeons commence the operation under the im- 
pression that it may be impossible to discover the colon, and 
even the best operators have often experienced difficulties or 
failures in finding the gut. Indeed, the small intestine has been 
frequently opened by mistake. Knowing this, and having read 
Mr. C. B. Lockwood's valuable pamphlet on the development 
of the colon and the abnormal positions it may assume, and 
from the experience derived from a case of my own, I resolved 
to attempt to discover the causes of these failures, and, what is 
more important, the methods by which they might be ob- 
viated. 

In previous pages 1 have fully described the anatomy 
of the regions encountered in lumbar colotomy, but a little 
repetition may be excused. It will be agreed that, unless the 
operator sees one of the longitudinal bands, which are invariably 
and only found in the large intestine, the intestine should not 
be opened from the loin. We are aware that these bands are 
situated, one on the anterior surface, another along the inner 
part, and the third at the posterior aspect of the gut. It is this 
posterior hand that is usually looked for, and generally sup- 
posed to be seen, when the bowel is sought for in lumbar 
colotomy. Some authorities hold that these bands can be 
readily detected without opening the peritoneum, but this is 
only rarely the case. I have observed, from an examination 



COLOTOUY. 345 

and dissection of over a hundred ascending and descending 
colons, that the bands are always more easily and distinctly seen 
when they are covered by the peritoneum, which makes them 
hard, prominent, and shiny ; whereas, when the peritoneum is 
stripped off them, these characteristics are lost. However, in 
eight out of the hundred cases examined, one or two of these 
bands could be seen, but not very distinctly, on the posterior 
part of the intestine, although they were uncovered by perito- 
neum. T\ hen the peritoneum only covers about one-half or 
two-thirds of the circumference of the gut, it is generally 
reflexed off the gut at the posterior margins of the longitudinal 
bands on to the walls of the belly. Thus the bands are not 
visible unless the peritoneum is stripped off; if an attempt be 
made to expose them, the peritoneum, owing to its being so 
firmly adherent to the band, is frequently torn and the abdom- 
inal cavity opened without the operator being aware of it. 

There are various ways in which lumbar colotomy has 
been performed ; the differences are in the direction of the 
lumbar incision and in the way of fixing up the gut when it 
has been found. 

Several years ago a careful investigation of more than fifty 
dissections led my father to the conclusion that the best incision 
from which the colon could be found was one with its centre 
quite half an inch (1.27 centimetres) posterior and midway 
between the anterior superior and posterior superior spines of 
the ilium, and midway between the last rib and the crest of the 
ilium. 

1. Callisen has used a vertical incision. This is made over 
the point discovered by my father, and takes a vertical direction. 
The disadvantages are the limited length of the incision that is 
possible and the difficulty of working down upon the gut. 

2. The transverse incision of Amussat. 

3. The oblique incision of Bryant. 

These last two incisions are the best, for, if room is wanted 
in difficult cases, thev can be enlarged. 



34() DISEASES OF THE RECTUM AND ANUS. 

When the gut has been found by any one of these incis- 
ions, it can be fixed in its place by various modes. 

When the gut is distended and has to be opened at once, 
some surgeons pass sutures through it in the following manner : 
A suture is passed first through one lip of the wound, then 
across and through the distended bowel, and finally through the 
opposite lip of the wound. Another suture is then introduced 
about an inch from the first one, and is treated in a similar 
manner. Next, the gut is opened, and the loop of the sutures 
is pulled out and divided. The four sutures thus formed are 
tied up, thereby securing the gut to the skin-edges. A few 
additional stitches may be put in if they are required. 

When lumbar colotomy is to be performed the patient is 
turned on his side, with a firm pillow under the loin nearest the 
table. What I usually find to make a hard and firm pillow is 
a large sheet rolled up and tied together with bandages. The 
instruments employed are a knife, scissors, clips, retractors, and 
needles. The loin is cleaned ; an incision is then made half an 
inch (1.27 centimetres) behind the point discovered by my 
father. Whether it be transverse or oblique, the incision should 
be two inches (5 centimetres) in length, — not more, for this 
limitation obliges the operator to cut down exactly to the position 
in which the colon generally lies ; whereas, if the incision is 
five or six inches (12.7 or 15.2 centimetres) long, there is a risk 
of missing the gut. Its centre should be over the chosen spot, 
midway between the last rib and the crest of the ilium. Di- 
vision being made of the skin and the cellular tissue, — the latter 
of which is sometimes very abundant, — the muscles are exposed 
and may be rapidly divided until the fascia lumborum is 
reached. This is opened and the quadratus lumborum is 
exposed at its anterior edge ; in some cases the quadratus may 
require division. The edges of the wound are then retracted 
and the fat which lies around the kidney and behind the fascia 
lumborum is torn through with dissec ting-forceps. After this, 
the gut, if it is distended and has no mesentery, will bulge into 



COLOTOMY. 347 

the wound. In straightforward cases, the fact that it is the 
colon will be shown by its being uncovered by peritoneum ; for 
if the peritoneum is opened, peritoneum will be seen surround- 
ing the gut. together with the longitudinal bands. There will 
then be no uncertainty as to its being the colon. It is then 
brought to the surface and very carefully stitched with inter- 
rupted sutures all around to the skin-wound. These sutures 
should pierce only the muscular coat, and should not in any 
way perforate the gut. 

If the case is not very urgent, the gut can be fixed in this 
manner and left unopened for a day or more till it is all glued 
up with lymph. It can then be opened. 

I am sure, from the anatomical researches previously nar- 
rated, that the cases are rare in which there is this absolute 
certainty of the actual presence of the colon without opening 
the peritoneum. I therefore at once proceed to explain what 
should be done if there are any difficulties in finding the 
colon or in making sure that the part exposed is that piece of 
intestine. 

The difficulties of the operation commence as soon as the 
transversalis fascia is opened. They arise from various con- 
ditions which are caused by the position of the intestine in 
relation to its peritoneal covering and length of mesentery. I 
will describe these conditions and explain the operative treat- 
ment necessary under each head. 

I. What is supposed to be the general position (as shown 
in Fig. 10S) is where the peritoneum covers only one-half or 
two-thirds of the circumference of the gut. lea vino- the posterior 
part uncovered, with the intestine bound down to the loin. 
According to Mr. Treves, this was the position in 74 out of 100 
cases on the right side and 64 out of 100 on the left side. 

My own observations, in which I was assisted by Dr. 
Penrose and the late Mr. Stewart Pollock, at St. George's 
Hospital, showed 11 out of 60 cases on the right side and 10 
out of 60 on the left side; thus, by taking the percentage. 18^- 



348 



DISEASES OF THE RECTUM AND ANUS. 



out of 100 cases on the right side and 16 J out of 100 on the 
left side. 

From this it would appear that this so-called general 
position is less common than is popularly supposed. 

When the intestine is in this state, and if a longitudinal 
hand he seen, which must be uncovered by the peritoneum, 
there should be little or no difficulty in the operation. When, 
however, no bands can be seen, owing to the peritoneum cover- 
ing them, the best distinction between large and small intestines 
is wanting. Therefore, knowing that the small intestine is fre- 
quently exposed by opening the peritoneum unwittingly, I 
refuse to run the risk of opening the small intestine under the 



Colon with 
no mesentery 



Vertehral 
column 




Peritoneum 



Fig. 108.— Position of Peritoneum in Condition 1. 



false impression that the peritoneum has never been opened at 
all and that I am dealing with the large intestine. Hence, in 
this condition, if after exposing a piece of intestine I fail to see 
a longitudinal band, I intentionally make a small incision into 
the parietal peritoneum, and convince myself, by searching for 
and finding a band, that I am actually engaged on the large 
intestine. The posterior part of the intestine is then drawn to 
the surface of the wound (the gut being pulled out as far as 
possible) and carefully stitched with interrupted sutures all 
round to the edge of the skin, the mucous lining not being 
perforated. 

The intestine may be left unopened for some hours or, if 



COLOTOMY. 349 

necessary, be opened at once, provided that it is carefully attached 
at every point to the surrounding edges of the skin-wound. 

II. In Condition 2, as represented in Fig. 109, the colon 
is entirely surrounded by firmly-adherent peritoneum, and has 
a comparatively short mesentery ; so that it is absolutely impos- 
sible to reach it or to see the longitudinal bands without first 
opening the peritoneal cavity. 

In this condition the ascending and descending colons 
have a mesentery of varying length. 

According to Mr. Treves, it was in 26 out of 100 cases on 
the right side and in 36 out of 100 on the left side. 

My own observations show 49 out of 60 cases on the right 




Co/on with 
short mesentery 



Peritoneum 



Fig. 109.— Position of Peritoneum in Condition 2. 

side and 50 out of 60 on the left side ; the percentage, there- 
fore, being 81f out of 100 cases on the right side and 83J out 
of 100 on the left side. 

In cases falling under this second head the operator 
should at first seek for the gut about the subperitoneal tissue, 
under the assumption that it is in its supposedly normal po- 
sition ; but should this search fail, all the loose pieces of fat 
must be sponged out of the wound. The peritoneum at the 
anterior angle of the wound should be deliberately opened (and 
the edges clipped) just, sufficiently to admit the index finger. 
Pass this finger toward the vertebras and then sweep it over 
the front of the kidney and the quadra tus lumborum. The 



350 



DISEASES OF THE RECTUM AND ANUS. 



gut, although it is in the position shown in the figure (109), 
can be easily felt and hooked up, and the longitudinal bands be 
seen. Next open the peritoneum to the extent of the wound 
and introduce a sponge, with string attached, to keep the intes- 
tine out of the way while the edges of the cut peritoneum are 
drawn up and sutured to the skin in the manner adopted in 
inguinal colotomy. This entirely shuts off the cut abdominal 
muscles from the peritoneal cavity. Sometimes this stitching is 
not easy to do, either because of the depth of the wound or 
from the firm adherence of the peritoneum to the abdominal 
wall. The rest of the operation is completed as in Condition 1. 
If the mesentery be long enough, a stitch may be passed 



Peritoneum 



Vertebral 
column 




Colon with 
very long 
mesentery 



Fig. 110.— Position of Peritoneum in Condition 3. 



through it, fixing it to the surface of the wound ; thus a good 
spur may be obtained. 

III. In Condition 3, as shown in Fig. 110, the state of 
things in Condition 2 is much intensified and the mesentery 
is very long; thus the intestine, although it may rest in the 
loin, can so alter its position in the belly that, when the oper- 
ation is done on either side, it may lie on the side of the belly 
opposite to that in which the incision is made. This is the 
condition in which it has been said and supposed to be impos- 
sible to find the colon from the lumbar region. 

If, after proceeding in the manner described under Con- 
ditions 1 and 2, you have failed to find the colon, enlarge the 



COLOTOMY. 351 

external wound forward and backward sufficient to admit the 
hand. Then open the peritoneum to a corresponding extent, 
and, having well cleansed the hand, introduce it into the abdo- 
men. If it is the left colon that is to be operated on. first pass 
the hand upward toward the spleen and feel for the splenic 
flexure. Hereupon draw the hand down the intestine until the 
piece opposite the wound is found and brought to the surface. 
Failing to find the intestine at its splenic bend, pass the hand 
toward the rectum or across the abdomen (keeping the back of 
it in contact with the posterior aspect of the anterior abdominal 
wall) toward the hepatic flexure, and slip the hand along the 
large intestine and draw a piece to the surface. Of course, take 
care to ascertain that this piece of intestine has the characteristic 
longitudinal bands. The presence of the appendices epiploicae 
may also show that the large intestine has been discovered, but 
they may be absent from the particular piece drawn out. By 
the use of this method I have never had any difficulty in finding 
the colon. 

When the lar^e intestine has been found, command it with 
forceps that will not perforate the gut and introduce a sponge 
to keep out the small intestine, which may prolapse while the 
wound is treated as follows : — 

At the anterior and posterior parts (if the incision is six 
inches — 15.2 centimetres — long) two inches (5 centimetres) in 
front and two inches (5 centimetres) behind should be dealt 
with as in an ordinary case of abdominal section, by passing the 
sutures through the skin and peritoneum, so as to bring the cut 
peritoneal edges into contact. But at the middle two inches (5 
centimetres) of the wound, where the intestine is to be brought 
up to the surface, the peritoneum should be sutured to the skin 
as described under Condition 2. and the operation be completed 
in the same way. In this third condition a good spur can and 
should always be made, and when the gut is opened its promi- 
nent edges ought to be cut away in the manner described for 
inguinal colotomy. 



352 DISEASES OF THE RECTUM AND ANUS. 

I must here mention that most of the details of these sug- 
gestions have heen arrived at from operations on the dead body ; 
for it has not yet been my fortune to come across cases in my 
own practice that required such treatment, although I have seen 
cases operated upon in which these methods would have been 
extremely advantageous. 

When I first advocated the foregoing lines of treatment I 
expressed my surprise that in spite of the frequency of the opera- 
tion of lumbar colotomy these details appeared to be so little 
known or, at any rate, practiced ; though I was inclined to 
believe that they must have occurred to, or been used by, some 
surgeons. Thus I was encouraged to break the silence on the 
way of finding or treating the large intestine from the loin. I 
am still confident that whenever I perform the lumbar operation 
I shall never have any fear of failing to find the colon. 

There are other difficulties which mav be encountered in 
the operation, but they are of trifling importance when com- 
pared with those that arise from the movements and relations 
of the intestine to its coverings. 

An empty bowel is, of course, extremely difficult to find if 
the peritoneum is not opened, but it is easily discovered by the 
method I have explained. Unless that mode of dealing with 
the gut is utilized, great trouble and unnecessary disturbance of 
the cellular tissue may result. 

Perhaps, after the tissue has been pulled about and 
bruised, the surgeon who is afraid to open the peritoneum may 
do so by accident and thus find the gut. By my plan he will 
certainly find it. Unless the peritoneum is opened, either 
knowingly or unintentionally, the operation might have to be 
abandoned. 

A very fat loin may be a source of trouble, and those 
surgeons who still wish to avoid opening the peritoneum when 
it ought to be opened may find it expedient to enlarge the in- 
cision considerably. This necessity of enlarging the external 
wound will be spared those who follow my plan, for as soon as 



COLOTOMY. 353 

the peritoneum is opened the gut is easily found and can be 
treated in the way thought best. 

In these cases, not only the subcutaneous, but the sub- 
peritoneal, tissue may be greatly increased in amount ; thus, if 
the peritoneum be not opened there may have to be a difficult, 
tedious, prolonged, and unnecessary search in this tissue for the 
posterior part of the gut, provided, that is to say, that the gut 
is in its place and uncovered by peritoneum. 

We have already discussed the question of the mesocolon 
and abnormalities of the colon. It is possible that, in rare 
instances, the colon might be congenitally absent from the side 
operated upon ; then, if the peritoneum has been opened and a 
good search been made with the hand in the belly, and it is 
found impossible to drag down any other part of the colon and 
fix it to the loin, you should close the lumbar wound and 
perform a colotomy on the other side of the body. 

Prolapse is a very important matter. A small prolapse of 
the mucous membrane alone is of but trivial consequence, but 
what I refer to is a procidentia of the gut through the loin- 
opening. I have frequently seen this condition. It may take 
place not only from the upper, but also from the lower, portion 
of the gut, and even from both portions together. The up- 
holders of the lumbar as against the inguinal operation assert 
that this procidentia rarely occurs ; but I have seen several 
cases of it (Figs. Ill and 112 are instances), and it is quite as 
common as after inguinal colotomy. Its occurrence, therefore, 
is as much a drawback to the lumbar mode as it was to the 
inguinal method, till a supplementary operation was devised. 

The Spur. — Another disadvantage of lumbar colotomy is 
the absence of a spur, for, as a rule, it is difficult to pull the 
gut sufficiently well out of the wound to make a good spur, 
and, further, unless the mesentery is of a medium length or long, 
it is not easy to make use of the mesenteric stitch. Moreover, 
some surgeons do not sufficiently appreciate the importance of 
the mesenteric stitch, and do not trouble to make one, even 

23 



354 



DISEASES OF THE RECTUM AND ANUS. 



when they can. As already pointed out, unless a spur is 
made, a fecal fistula is formed instead of an artificial anus. 
Consequently, in place of all the feces passing by the loin, a 
certain amount passes beyond the opening to the rectum and 
distresses the patient greatly. The patient will possibly blame 
the surgeon for this result, for he may have been assured 
that, after the operation, no more motion would pass by the 
rectum. He will be miserably disappointed, then, if a motion 
should pass beyond the lumbar opening, and, by irritating the 




Fig. 111. — Procidentia from Both Openings After Lumbar Colotomy. 



growth, cause pain and bleeding and, perhaps, even a continu- 
ance of the troublesome diarrhea. If the operation has been 
done to relieve the above distresses, rather than any obstruction, 
such after-results from the neglect to make a spur will, I hold, 
render it a complete failure, and the patient may not unreason- 
ably hold the same opinion. 

The anatomical arrangement of the colon, as compared 
with that of the sigmoid flexure, and the manner in which the 
operation is usually performed, make it certain that the passage 
of feces below the opening is a far more frequent cause of dis- 
tress after lumbar than it is after inguinal colotomy. 



COLOTOMY. 



355 



The foregoing are more or less remote discomforts. We 
now turn to certain discomforts, or even calamities, that may 
occur within a short time of the operation. 

Cellulitis is not at all an uncommon consequence of lumbar 
colotomy, and is naturally most frequent when the gut has to 
be opened at once. There are several obvious reasons for this : 
first of all, the depth of the tissue and the looseness of the 
structures which have to be divided ; secondly, from its fixed 
nature, and from the depth of the wound, it is often impossible 
to fix the parietal peritoneum to the skin, and thus shut off the 




Fig. 112.— Procidentia from Both Openings After Lnrnbar Colotomy. 



various planes of cellular tissue, as can be done in the inguinal 
operation. Consequently, as soon as feces pass these planes, 
they become inflamed and suppuration sets in, frequently extend- 
ing backward to the spine, and even at times burrowing amongst 
the abdominal muscles in front. 

I have seen a patient recover from the immediate effects of 
the operation, but die in a week or two solely from this exten- 
sive, sloughing cellulitis. There is less chance of this happen- 
ing if the gut is not pricked or opened for, say, twelve hours or 
two or three days, for by that time the cellular planes are glued 
off by lymph, and such a calamity is then of rare occurrence. 



356 DISEASES OF THE RECTUM AND ANUS. 

Peritonitis is another after-result. As far as I am aware, 
this never takes place unless the peritoneum has been opened 
and feces have been allowed to run into it. It is most usual 
when the surgeon has unwittingly opened the peritoneum, 
stitching the gut to the skin in a rather careless manner, and 
then opening it, some of the feces thus escaping into the 
abdominal cavity. 

If the peritoneum is intentionally opened, the operator can 
take great care to close off the peritoneum when the gut comes 
through it, and, further, can be especially attentive in sewing 
the gut thoroughly all round to the edges of the skin-wound, 
so as to leave no space through which feces can find their way 
into the belly. If this is done in the manner already described, 
there is very little risk of peritonitis, even if the gut has to be 
opened at once. 

Exhaustion, erysipelas, eczema, and so forth, may super- 
vene on colotomy, as they may do on any other operation. 

Right Lumbar Colotomy. 

In the performance of right lumbar colotomy exactly the 
same details must be pursued as in the left side. Precisely the 
same difficulties may be encountered and the same after-results 
may happen. A repetition of them is, therefore, unnecessary. 

We may remark that on the right side there is usually a 
fair-sized mesentery to the colon ; so that it is even more neces- 
sary to be careful in operating and to guard against any after- 
prolapse. It is not so imperative to make a good spur, for there 
is a considerable distance between the opening and the rectum. 
Moreover, the growths or pressure upon the colon, whether 
transverse or left lumbar, are not in the same ulcerated, painful 
condition as they are in cases of rectal cancer. As a rule, they 
are of a hard, slightly ulcerated, and very contracting variety, 
which leads rather to obstruction than to pain, bleeding, 
discharge, and so forth. 



COLOTOMY. 357 

Transverse Colotomy. 

I have previously discussed the anatomy of the parts 
involved in this method of colotomy. It is not frequently per- 
formed, and I have met with only few cases of it, — three in my 
own practice, one in Mr. W. H. Bennett's, and a fifth under 
the care of Mr. G. It. Turner, hoth of St. George's Hospital. 

The operation is done in the following manner : An incision 
is made through the skin and the left rectus abdominis is ex- 
posed. Then separate its fibres with the fingers and incise the 
posterior part of its sheath formed by the divided tendon of the 
internal oblique muscle. That being done, the subserous areolar 
tissue is exposed and the peritoneum picked up and divided. 
The parietal peritoneum is then stitched to the skin all round 
the wound, as in inguinal colotomy, and for the same reasons. 
In some cases the great omentum presents. This must be 
pushed upward toward the stomach, and the large intestine is 
then found and recognized by its longitudinal bands. The in- 
testine is next pulled forward and fixed well outside the abdo- 
men ; if a spur is required, the mesenteric stitch is used as in 
inguinal colotomy. The gut is then secured to the skin in 
several places by passing sutures through the peritoneal and 
muscular coats ; great care must be taken that the gut is not 
perforated anywhere, for, if it is, gas or feces might escape at the 
prick-holes and peritonitis result. 

In my first case I used as an exploratory incision, in the 
first instance, the incision which is always made above the 
umbilicus. It was, therefore, made large enough for the intro- 
duction of the hand into the abdomen, so as to discover where 
the obstruction was. When this has been ascertained, and a 
transverse colotomy has been decided upon, the wound must be 
closed with the exception of the upper tw T o inches (5 centimetres), 
the lower part being brought together as in an ordinary abdom- 
inal section. The upper two inches (5 centimetres) are treated 
as in inguinal colotomy, the parietal peritoneum being stitched 
to the skin, and through these upper two inches (5 centimetres) 



358 DISEASES OF THE RECTUM AND ANUS. 

the transverse colon is brought and fixed into that space. 
Unless the case is a very urgent one it is wiser not to open the 
gut until about two days after it has been fixed up, for by that 
time all communication of the wound with the peritoneal cavity 
is completely glued off by lymph. The gut is opened by 
scissors in a vertical direction. Some days or a week later, if 
the proceeding is deemed necessary, any excessive portions of 
the walls of the gut may be removed on a level with the skin. 

I have not yet become acquainted with any difficulties in the 
operation. I imagine that there might be some little trouble in 
finding the colon, though I cannot understand how that could 
very well be. 

In this operation, as was said with regard to the right 
lumbar and the right inguinal modes, there is not much neces- 
sity to make a very perfect spur, except in cases in which the 
large intestine communicates with some viscus, such as the 
bladder. Then, indeed, a spur is most necessary to prevent any 
feces passing beyond the transverse colotomy-opening into the 
lower part of the gut, and thus through the fistula, — say, into 
the bladder. Were this to happen, the purpose of the operation 
would be entirely defeated. 

Prolapse might happen, but I have not yet seen it, and it 
would scarcely be so likely to occur as in other places, for the 
transverse colon is, in a way, fixed at its hepatic and splenic 
flexures, and would thus tend greatly to prevent any prolapse 
of the gut through the transverse opening. 



CHAPTER XXVIII. 

ARTIFICIAL ANUS AND FECAL FISTULA. 

We differentiate between these two conditions because 
the former is made intentionally and for the relief of some 
pathological condition of the bowel wherein it is not desirable 
to have the feces discharged through the rectum. The latter 
is usually the result of obstruction, a fecal abscess, strangu- 
lated hernia, a penetrating wound, or sometimes a surgeon's 
failure to make a satisfactory spur in colotomy. In a fecal 
fistula the feces are discharged both through the rectum and 
the fistulous opening. In a large percentage of the cases where 
an artificial anus has been made it is expected to be perma- 
nent. On the other hand, a fecal fistula produces great annoy- 
ance from the almost constant discharge through the opening; 
hence, it is desirable to close it. To do this it often taxes all 
the skill of the operator. 

Treatment. — When the gut simply adheres to the abdomi- 
nal wall and communicates with the external part through a 
small opening, the tract can frequently be made to heal by care- 
ful dieting, thorough cleanliness, and the aid of stimulating ap- 
plications, such as the nitrate of silver, etc., to the edges of the 
wound, or by the actual cautery. When these fail the edges 
of the opening should be pared and adjusted nicely with a suf- 
ficient number of catgut or silk sutures. We have used suc- 
cessfully this latter procedure in two cases. To close an 
artificial anus or a fecal fistula, where the serous surfaces of a 
loop of the intestine have grown together forming a spur, is 
much more difficult than to close a simple fecal fistula, for the 
reason that we have two openings into the bowel, one leading 
into the upper and the other into the lower portion, separated 
by a bridge or a pouched portion of the gut covered by mu- 
cous membrane ; this bridge must be destroyed before the con- 

(359) 



360 DISEASES OF THE RECTUM AND ANUS. 

tinuity of the upper and the lower portions of the intestine can 
be established. Many operations and instruments have been 
devised for this purpose, but none as yet have proved entirely 
satisfactory. Perhaps Dupuytren has thrown more light upon 
the treatment of these conditions than any other one man ; he 
was the inventor of the enterotome which bears his name. 
To destroy the spur take a Dupuytren or Gross enterotome 
or a pair of strong clamp-forceps the blades of which have 
serrated edges with a firm catch in the handle, similar to those 
used for grasping large pedicles, and insert the blades of the 
instrument into the two openings and press them inward until 
the major portion of the spur is between them. Then close 
them cautiously, to avoid including a coil of the small intestine, 
and fasten the handles tightly together. The instrument is left 
in situ until it comes off of its own accord, thus destroying the 
spur, which allows the passing of the feces from the upper to 
the lower portion of the gut. When this has been successfully 
accomplished, the skin and edges of the opening should be 
freshened and brought into close apposition by catgut or silk 
sutures. It is well, also, to put in two deep silk-worm-gut 
sutures some distance from the edge of the wound, which act 
as a splint in case of vomiting. Some prefer to destroy the 
spur by the ligature, which is passed through it as deeply as it 
can be with safety. That part external to it is then ligated and 
the ligature allowed to cut its way out. We would suggest to 
those who use the ligature that an elastic one be selected simi- 
lar to those described for the cure of fistula by the ligature 
method. They consist of a solid piece of India rubber, about 
the sixteenth of an inch (1.7 millimetres) in diameter, which is 
adjusted tightly and secured by means of a bullet's pressing the 
two ends together. 

When less radical means fail, such as those just described, 
we are justified in dissecting the bowel loose from the abdom- 
inal wall. Then that portion of the bowel including the spur 
is excised and the two ends of the bowel united by a lateral or 



ARTIFICIAL ANUS AND FECAL FISTULA. 361 

an end-to-end anastomosis. This can be accomplished with 
little danger as compared with former times, since we have the 
Abbe catgut rings, the sectional ones of Browkaw, the vegetable 
or decalcified-bone plates of Senn, or the Murphy button, all 
of which have proved great boons to intestinal surgery by less- 
ening the mortality of these operations. The abdominal wound 
can then be closed in a way best suited to the judgment of the 
operator. 



CHAPTER XXIX. 

WOUNDS AND INJURIES. 

The rectal surgeon is not infrequently called upon to 
remove from the bowel foreign bodies which have been swal- 
lowed, accidentally forced into the rectum, or placed there by 
the patient for some purpose. Numerous cases of the latter kind 
have been reported among insane people. Again, criminals 
have used the rectum to conceal money or tools with which to 
make their escape. Other cases have been reported where false 
teeth and articles of dress have been swallowed and lodged in 
the rectum. One gentleman used this portion of his anatomy 
for the purpose of concealing a large number of diamonds to 
escape paying the usual duties. M. Marchetti reports an in- 
teresting case where some students, while on a lark, introduced 
into the rectum of a prostitute all save the small extremity of a 
pig's tail from which they cut enough of the bristles to make it 
as rough as possible. Various attempts were made to remove 
it, but all failed, owing to the bristles catching in the mucous 
membrane. Finally he slipped a cannula around it, which pro- 
tected the bowel while it was being removed. Many very 
interesting cases of the introduction of bottles, knives, sticks, 
potatoes, turnips, etc., have been reported, but we shall not have 
time to review them at length. We wish at this time, however, 
to record a case that occurred in the practice of a former pupil 
of the author's, wherein a man lost his life as the result of a 
large stick having been accidentally forced into the bowel for 
several inches : — 

Case XXXIII. — Stick in the Rectum ; Death from Peritonitis. 
A few months since one of my former pupils, Dr. Hawthorne, pre- 
sented me with a stick which he had removed from the rectum of a 
gentleman who died, several hours after the operation, from peritonitis. 
He gave me the following history of the case : He had been called 
(362) 



WOUNDS AND INJURIES. 



363 



hurriedly, on the afternoon of September 1, 
1893, to see Mr. B., of Kansas, aged about 
65 years. On arriving at the bouse he 
found the old gentleman suffering excruci- 
ating pain caused U3- a large stick which 
was projecting from his anus. He told the 
doctor that for a number of }"ears he had 
been suffering from a very annoying itching 
about the anus, which was made more in- 
tense every time the bowels moved, and. to 
get temporary relief, he had been in the 
habit of taking a chip or stick and scratch- 
ing himself. On this particular occasion 
he had selected a very knotty one about an 
inch (2.54 centimetres) in diameter and about 
ten inches (2.5 decimetres) in length (see 
Fig. 113), which had a hook about two 
inches from the end. With it he was enjoy- 
ing the luxuries of a good scratch when his 
feet slipped from under him and the stick 
came in contact with the ground and was 
forced into the rectum for about two inches 
(5 centimetres) ; an attempt was made to 
withdraw it, but he was unable to do so, for 
the hook had caught in a fold of the mucous 
membrane. He endeavored to release it by 
pushing it farther up the bowel and then 
withdrawing it, but it became fastened 
again ; he made several futile attempts, get- 
ting the stick higher up the bowel each time. 
Finally he gave up in despair and called his 
wife and son, who carried him to the house 
and placed him in bed ; his son then tried to 
remove it by force, causing much pain and 
bleeding. Finally he became frightened and 
Dr. Hawthorne was called in. On making 
an examination he found that the hooked 
portion of the stick had caught in the pos- 
terior wall of the rectum about six inches 
(15 centimetres) above the anus. It was 
pushed upward until the point of the hook 
was released ; the sharp point was covered 



h 



« 



IS, 



1 



Fig. 113.— Stick Removed from 
Rectum. (Half natural size.) 



364 DISEASES OF THE RECTUM AND ANUS. 

by the finger and the stick withdrawn without further difficulty. 
This, of course, was done under an anesthetic, for it was necessary 
to force the hand partly into the rectum. There was considerable 
bleeding, and a rent was found through the peritoneum about three 
inches (7.5 centimetres) in length. A consultation was advised and 
Dr. E. W. Baird, of Tescot, Kansas, was called. It was thought best to 
keep the rectum clean by antiseptic irrigations and the bowel quiet by the 
use of large doses of morphine and give nature a chance to heal up the 
rent. The patient continued to grow worse. The temperature was high, 
the pulse vei*3 T fast and thread-like, the pains increased in severity, and 
the abdomen rapidly distended with gas until it was almost as tense as a 
drum-head. He became unconscious, and thirtj^-six hours from the time 
the stick was forced into the rectum the patient died from peritonitis. 
This case is another example where a life was sacrificed by the laity in 
living to avoid paying a surgeon's fee, for there is not a question that 
if the} r had called Dr. Hawthorne when the accident first occurred he 
would have removed the stick without doing any harm to the bowel. 

Symptoms. — The symptoms of foreign bodies in the rectum 
are usually urgent if the body is large enough to cause obstruc- 
tion, and if the edges are sharp and lacerate the bowel there 
will be more or less pain, hemorrhage, and the usual symptoms 
of obstruction. Many times abscess and fistula result from the 
irritation set up by a pin or fish-bone that has been swallowed 
long ago. 

Treatment. — All foreign bodies should be removed at once 
and with great care. Not infrequently an accumulation of 
fecal matter may form a hard lump and act as a foreign body. 
This, however, will be considered under the subject of "Im- 
pacted Feces." 

Injuries. 

The rectum is rarely the seat of accidental injury. It has 
been only a short time, however, since we were called to see a 
severe laceration of the rectum and anus of a boy, 12 years old, 
who had fallen out of a tree, striking on a picket-fence. Sur- 
gical operations about the lower portion of the bowel for hemor- 
rhoids, fissures, and ulceration are of frequent occurrence. 
We have seen several persons who had injured themselves by 



WOUNDS AND INJURIES. 365 

the careless introduction of the end of a syringe, and we have 
pushed a bougie through the rectal wall by using more force 
than was justifiable in trying to diagnose a stricture high up. 
We can readily perceive how one might rupture the rectum 
during rapid dilatation, as some authors recommend, in cases of 
stricture, especially where the bowel is ulcerated. Gunshot 
wounds are of comparatively rare occurrence. We were called 
to a nt^hborino: city, a little over a year ago, to see a burglar 
who was shot in the anus by a policeman while attempting to 
climb a fence to escape. The ball passed through the rectum 
and came out at the right groin. The wound was washed daily 
with a bichloride solution and packed with gauze, and the 
patient made a good recovery. The rectum is not infrequently 
injured during childbirth. The symptoms o( wounds in tins 
locality are similar to those of wounds in other parts of the 
body, except that of hemorrhage, which may remain concealed 
within the bowel. 

Treatment. — If the wound be lacerated or incised, bring 
the edges together and suture them, for it is always desirable to 
get prompt union. Cleanliness must be strictly observed. In 
case there is severe arterial hemorrhage a ligature should be 
adjusted around the vessel. If the hemorrhage seem to be 
general, it can be arrested by pressure applied with a sponge 
saturated with hot water or by the application of Monsell's 
powder. When the wound is severe rest in the recumbent 
position should be insisted upon, and if there be much pain 
one-fourth of a grain of morphine hypodermatically will 
relieve it. 



CHAPTER XXX. 
NEURALGIA OF THE RECTUM. 

Neuralgia of the rectum and coccygodynia are so similar 
in many respects that we will speak of them under the same 
heading. Those who treat many cases of rectal diseases now 
and then have a patient who comes to them suffering from 
severe pain having its seat in the rectum, in the coccyx, or in 
the sacro-coccygeal region. It is paroxysmal and is of a lanci- 
nating or burning character. Examination will reveal the 
absence of any heat, tenderness, or swelling, and in many 
instances no cause whatever can be found that is sufficient to 
account for the suffering. This condition we have been in the 
habit of designating neuralgia of the rectum. This term is not 
used for the reason that it is particularly expressive of the con- 
dition or the location of the disease, but from the usage of the 
term neuralgia. Similar pains situated in other parts of the 
body are designated neuralgia of the part involved. Recent 
writers have given this peculiar condition much thought, some 
claiming that it is only an hysterical condition and others that 
it is a result of an injury or the misplacement of some organ. 
It is found more frequently in women than in men, and in those 
of a nervous temperament, and occurs when there is some 
general impairment of health or in those who have been injured 
by a fall or a kick on the coccyx. Sometimes there is a congen- 
ital misplacement of the coccyx (see Figs. 114 and 115) to one 
side or the other, and constant sitting on a hard seat will cause 
much pain. We remember two cases of this kind in school- 
girls, besides a number of others. 

In many of the cases simulating neuralgia of the rectum, 

if a thorough examination is made, a fissure or an irritable 

ulcer will be found that is sufficient to account for the pain, for 

we all know that the pain in fissure nearly always radiates 

(366) 



NEURALGIA OF THE RECTUM. 



367 



toward the coccyx. When no local cause can be found we 
must seek an explanation in some sympathetic or reflex irritation 




Fig. 114.— Diagrammatic Drawing showing Deviation of the Coccyx Anteriorly. 

produced by a misplaced or diseased organ. At times the neu- 
ralgia may follow exposure from sitting on cold steps or damp 




Fig. 115. — Diagrammatic Drawing showing Deviation of the Coccyx Posteriorly. 

grass. Again, irregular habits have been known to get the 
general system into a state conducive to neuralgia. In the 



368 DISEASES OF THE RECTUM AND ANUS. 

majority of cases, however, the pain will be due to some local 
pathological condition in the rectum or is reflected from some 
other organ, just as in hip-joint disease the pain is reflected to 
the knee. The pain is increased by violent exercise, and fre- 
quently becomes worse after sitting in one position for some 
time or on getting up or sitting down suddenly or during 
defecation. 

Diagnosis. 
The diagnosis is made by the peculiar location and character 
of the pain and the absence of any visible cause. When it is 
due to a dislocated coccyx there will be much pain when it is 
pressed upon or moved from side to side. Sometimes it becomes 
ankylosed and immovable. 

Treatment. 

In every case search out any local diseased condition that 
might cause the pain, correct the same, and a good result will 
follow. When it is due to fissures or ulcers, thorough divulsion 
or division of the sphincter, followed by a few applications of 
silver nitrate 15 grains to the ounce, will cure them. When the 
neuralgia is due to some enlargement or displacement of the pros- 
tate, uterus, or other organ, they must undergo treatment first, 
else any remedial agents directed for the cure of the paroxysmal 
pains will be of no avail. In some the pain is due to a fractured 
or dislocated coccyx, which must be removed at the earliest time 
possible. We have removed the coccyx a number of times for 
the cure of neuralgia following an injury, and every time the 
patient was cured. 

The number of epileptic seizures frequently diminish after 
the removal of an offending coccyx. We have a case under 
observation who had from three to seven seizures daily before 
operation. For two weeks afterward he did not have one; on 
the sixteenth day, however, he became slightly dizzy, but did 
not lose consciousness. It is now two months since the seg- 
ments of the coccyx were removed, and in one instance only has 



NEURALGIA OF THE RECTUM. 369 

he become unconscious. In this case the coccyx was deviated 
posteriorly (see Fig. 115) to such an extent that it pained him 
constantly when sitting down or lying in bed. Since its removal 
he rests comfortably in any position. At this time we anticipate 
a permanent recovery from his epileptic seizures, for it appears 
that we have removed the source of irritation which caused 
them. 

Operation. — The operation is performed by making an in- 
cision over and down to the coccyx ; the periosteum is then 
removed and the bone clipped off with a pair of ordinary bone- 
nippers and the periosteum replaced. The wound is then 
sutured with catgut and we get union by first intention. Drain- 
age is not necessary unless a hemorrhage is expected. 

Sometimes the Paquelin cautery-point, passed a few times 
over the seat of pain, will give immediate relief. We have also 
derived much benefit, in case of neuralgia of the rectum, from 
massage over the seat of pain every other day for three weeks, 
and when there is any tendency to constipation we use abdom- 
inal massage and daily injections of warm or cold water, giving 
preference to the latter. Opiates and narcotics in any form 
should be discouraged, for those affected in this way are nerv- 
ous and very likely to get into the habit of taking drugs when 
they are of no real value. If the sphincter is unusually tight 
we divulse it thoroughly. We have witnessed many remarkable 
cures from this simple procedure, and in closing would suggest 
that it be practiced in any case " where the sphincter has any 
tendency to spasmodic contraction and where no other local 
cause can be discovered." It is especially adapted to hysterical 
cases. 

ILLUSTRATIVE CASES. 
Case XXXIY. — Neuralgia of the Rectum. 
In December, 1892,1 was called to see Mrs. B.,aged 31 years, who, 
judging from external appearances, was in excellent health. On inquiry, 
she informed me that she had been suffering from severe spasmodic pains 
in her back off and on for the past six months. They were often so se- 
vere that she could not sleep at night. When asked to point to where the 

24 



370 DISEASES OF THE RECTUM AND ANUS. 

pain wns felt she placed her finger over the upper portion of the coecyx, 
and said that it sometimes went a little higher. Her bowels were regu- 
lar; she said she had never suffered from piles nor had any discharge 
from the rectum, and that pain was the only thing that anno} r ed her. 
For this she had been using suppositories composed of morphine and 
belladonna, which gave her only temporary relief. She desired to know 
if an operation were indicated. On examination, the coccyx, anus, and 
rectum proved to be perfectly sound and no fissure, ulceration, or in- 
flammation of the mucous membrane or adjoining skin could be located, 
although the examination was thorough. A medium-sized rectal bougie 
passed up the bowel for ten inches (2.5 decimetres) failed to cause any 
unusual pain or meet with any obstruction. I must confess that I was at 
a loss to know what caused the pain. After thinking the matter over I 
decided that she must be hysterical and only needed some trivial oper- 
ation to effect a cure. She was advised to have the sphincter muscles 
divulsed. To this she readily consented. On the following morning, 
under chloroform, the muscles were thorouglily divulsed in every direc- 
tion, the rectum was irrigated, and she was placed in bed. On the 
evening of the third day a Seidlitz powder was given and was followed 
by a copious movement, after which the rectum was irrigated again. 
From this time the patient was allowed to walk about the room. She 
did not complain of the pain once after the operation, and when she was 
discharged, after one w r eek's treatment, she said that she had never felt 
better. I had an opportunity of watching this patient for a } T ear or more 
and know that the pain never recurred. Just why the stretching of the 
sphincters cured this patient I am unable to full} 7 understand; possibly 
her sufferings might have been imaginary. This, however, I am inclined 
to doubt, for she seemed a sensible woman. Again, there might have 
been some irritation of the terminal nerve-filaments from which the pain 
was reflected to the coccyx and the source of the irritation was destroyed 
b} T the stretching. 

Case XXXV.— Neuralgia Due to Scar-Tissue. 
Mr. J. M., aged 40, complained of very severe, aching pains almost 
constantly in the neighborhood of the coccyx. He had been operated on 
for internal piles one year previous and five tumors had been removed 
by the ligature. The pains in the region of the coccyx commenced six 
months after the operation. I made a very thorough examination and 
no local pathological condition was found other than a considerable 
amount of cicatricial tissue caused b} 7 the operation. Having previously 
tried divulsion with success. I determined to try it in this case. Chloro- 
form was promptly administered and the muscles were thorough!}' 



NEURALGIA OF THE RECTUM. 371 

divulsed in every direction. I was not satisfied with this, but took my 
blunt-pointed bistoury and incised the scar-tissue freely until there was 
no contraction. The after-treatment was the same as is the previous 
case except that a full-sized bougie was passed daily to prevent too 
much contraction. This patient made an uninterrupted recovery and is 
perfectly well to-day. I have studied this case very closely and have 
come to the conclusion that the pains were caused by the nerve-filaments 
being bound down by the scaj^-tissue. and that they were relieved either 
by the dilatation or the incisions and the permanent relief that followed 
was due to these operations. And why should not this be ? It is a well- 
known fact that we have similar pains produced in the stump where a 
limb has been amputated and the nerve has been left long and becomes 
engaged in the scar, and we know also that the pain immediatel}* stops 
when the nerve has been liberated. 

Case XXXVI. — Neuralgia Due to a Dislocated Coccyx. 

A lady, aged 30, general health good, came to me suffering from 
neuralgic pains about the rectum. She was very nervous, and said that 
she suffered pain when sitting on a hard seat, and. further, that she 
believed her trouble Avas due to a fall received some months previously. 
Examination revealed a normal rectum, but the coccyx was very promi- 
nent and the lower two segments were dislocated backward and attached 
by a narrow ligament. 

Treatment. — The sphincters were divulsed, the displaced segments 
of bone removed, the wound closed and dressed, and iodoform gauze 
applied and the patient put to bed. In ten da}~s she was well and six 
months later the pains had not returned. 



CHAPTER XXXI. 
SODOMY (PEDERASTY). 

This term is used to express unnatural intercourse (abuse) 
in a variety of ways. At one time it is used to designate inter- 
course between a man or a woman and some animal (bestiality) ; 
or, on the other hand, between man and man, man and boy, 
and between man and woman, where the male organ is intro- 
duced into the rectum for the purpose of gratifying sexual 
appetite. When of the latter variety (that is, when the penis 
is introduced per rectum) it is called by a different name, — 
" pederasty." 

Pederasty in its strictest sense means intercourse per rectum 
between male and male. It is with some hesitation that we 
have undertaken to discuss this subject, for the reason that 
topics of this kind are revolting to the educated and refined 
mind. There are so many diseases contracted about the rectum 
and anus during such acts or as a direct result of the same, 
however, that we do not feel justified in passing over it without 
at least a slight discussion. We shall confine ourselves to the 
study of pederasty alone, for the reason that the study of the 
unnatural relations that might exist between man and beast 
would be out of place in a work of this kind. We have not 
seen more than half a dozen pederasts in our own practice, and 
it is with much pleasure that we record the fact that Americans 
resort to this manner of gratifying their passions less frequently 
than any other nationality. One can search the literature for 
reports of such cases in this country and he will find but few in 
comparison to the large number that have been reported by 
writers on this subject in other countries. In the United States 
pederasts arc found only among sailors, soldiers, miners in the 
far West, and sometimes among farm-hands in the rural districts, 
where there are no prostitutes to satisfy their sexual desires. 
(372) 



SODOMY (PEDERASTY). 



373 



We do not know of but a single instance where a person has 
been detected in this act by our authorities. 

This vice is so common in some countries — China, Asia, 
France, Germany, and Austria — that the most rigid laws have 
been enacted to suppress it. Yet the French writers tell us that 
in spite of these precautions pederasts are increasing in number 
every year. It is said that they have places of meeting, that 
sometimes large numbers congregate in the same flat or neigh- 
borhood, and that in Paris it is not uncommon for professional 
pederasts (prostitutes) to walk the streets in search of those 
who indulge themselves in this nefarious practice. It is further 
stated that they readily recognize each other by their actions and 
manner of dress, the passive pederast inclining to femininity. 

To show the. large number of pederasts in France and the 
physical signs by which they can be detected we will quote 
from an elaborate paper by Tardieu,* from which the following 
statements are taken : He says that during attempts made by 
the police to suppress pederasty in Paris he had the opportunity 
of examining on one occasion 97 and on another 52 persons 
taken in the act. He also visited at different times 60 others, 
besides examining many dead bodies of persons on whom the 
crime had been practiced. With regard to ages and occupations 
he gives the following table : — 



Age. 



12-15 years, 
15-25 years, 
25-35 years, 
85-45 years, 
45-55 years, 
55-65 years, 
65-75 years, 
Not given, 



Number. 



13 
65 
26 
28 
18 
5 
4 
46 



Occupation. 



Servants 

Merchants' clerks 

Tailors 

Military men 

Others belonging to 59 different oc- 
cupations . 



Number. 



44 
29 
12 
12 

108 



Casper states that persons may be pederasts of long stand- 
ing and show no signs of it ; but Tardieu says that out of 205 



Ziemssen's Cyclopedia, vol. xix, p. 53. 



374 DISEASES OF THE RECTUM AND ANUS. 

avowed pederasts he has only found 14 in whom it was impos- 
sible to find an evident trace of their habits. Out of this total 
those whose habits are exclusively passive numbered 99 ; those 
with habits exclusively active, 18; both active and passive, 71 ; 
not given, 17. 

With this immense experience, he gives the following as 
the effects of this peculiar perversion : — 

Physical Signs. — Passive pederasty produces excessive de- 
velopment of the buttocks, an infundibuliform appearance of 
the anus, relaxed sphincter, effacement of the folds, carunculse 
of the anal orifice, incontinence of feces, ulcerations, fissures, 
and so forth. 

The infundibuliform anus has generally been considered a 
pathognomonic sign. It is, however, not always present, but 
was found in 100 cases out of 170. It may be absent in 
persons with very fat or very thin buttocks. Tardieu believes 
relaxation of the sphincter to be fully as true and characteristic 
a sign. He found it in 110 out of 170 cases. 

The natural folds and puckers are effaced and the anus is 
smooth and polished, — the podex Jcevis of the Romans. The 
use of emollients to facilitate approaches causes relaxation of 
the tissues to such an extent as to produce a sort of prolapse of 
the mucous membrane; so that in several cases it resembled the 
labia minora of the female. 

In active pederasts the penis was found very small or very 
large. 

The large penis is rare, but in all cases the dimensions of 
the organ are excessive in one sense or the other, — i.e., of the 
organ when not in a state of erection. Its form is very charac- 
teristic. When small and thin it diminishes toward the glans, 
which is quite small; so that the penis resembles that of a dog. 
This is the most common shape, and suggests the idea that the 
tendency of some individuals toward this unnatural vice may 
be due to an incapacity for ordinary sexual intercourse. 

When the penis is voluminous the whole organ does not 



sodomy (pederasty). 375 

taper in size. The glans only is elongated, and the penis is 
twisted upon itself so that the meatus is directed obliquely 
toward the right or the left. This distortion is sometimes very 
marked, and appears more pronounced as the dimensions of the 
organ are more considerable. 

We will now endeavor to show how these miserable people 
descend so low in the social scale as to become habitues to this 
practice and why, when once begun, they seldom give it up. To 
do this in the rational way it will be necessary to distinguish 
between active and passive pederasty. 

An active pederast is the one who introduces the male 
organ. A passive pederast is the one who receives the male 
organ. 

In endeavoring to show how these people contract this 
deplorable habit we shall follow the classification given by von 
Krafft-Ebing,* which appears to us to be the most rational one 
and which is as follows : — 

Active pederasty occurs : — 

1. As a non-pathological phenomenon : — 

(a) As a means of sexual gratification, in cases of great 
sexual desire, with enforced abstinence from sexual intercourse. 

(b) In old debauchees, who have become satiated with 
normal sexual intercourse and more or less impotent, and also 
morally depraved, and who resort to pederasty in order to excite 
their lust with this new stimulus, and aid their virility, that has 
sunk so low psychically and physically. 

(c) Traditionally, among certain barbarous races that are 
devoid of morality. 

2. As a pathological phenomenon : — 

(a) Upon the basis of congenital contrary sexual instinct, 
with repugnance for sexual intercourse with women, or even 
absolute incapability of it. But, as even Casper knew, peder- 
asty under such conditions is very infrequent. The so-called 
urning satisfies himself with a man by means of a passive or 

* Krafft-Ebing (Chaddock), 7th German edition, p. 426. 



376 DISEASES OF THE RECTUM AND ANUS. 

mutual onanism or by means of coitus-like acts (coitus inter 
femora) ; and he resorts to pederasty only very exceptionally, 
as a result of intense sexual desire, or with a low or lowered 
moral sense, out of desire to please another. 

(b) On the basis of acquired contrary sexual instinct, as a 
result of long years of onanism (masturbation), which finally 
causes impotence for women with continuance of intense sexual 
desire. Also, as a result of severe mental disease (senile 
dementia, brain-softening of the insane, etc.), in which, as 
experience teaches, an inversion of the sexual instinct may take 
place. 

Passive pederasty occurs : — 

1. As a non-pathological phenomenon : — 

(a) In individuals of the lowest class who, having had the 
misfortune to be seduced in boyhood by debauchees, endured 
pain and disgust for the sake of money and became depraved 
morally, so that, in more mature years, they have fallen so low 
that they take pleasure in being male prostitutes. 

(h) Under circumstances analogous to the preceding, as a 
remuneration to another for having allowed active pederasty. 

2. As a pathological phenomenon : — 

(a) In individuals affected with contrary sexual instinct, 
with endurance of pain and disgust, as a return to men for the 
bestowal of sexual favors. 

(b) In urnings who feel toward men like women, out of 
desire and lust. In such female men there is a horror femince 
and absolute incapability for sexual intercourse with women. 
Character and inclinations are feminine. 

This classification is said to include all the empirical facts 
that have been gathered by legal medicine and psychiatry. 

Since we now understand how these deplorable people 
become pederasts, we will turn our attention to the diseases 
about the rectum and the anus that may be contracted as a 
result of this practice. They are not a few, for the male prosti- 
tute may contract just the same diseases in this way that the 



SODOMY (pederasty). 377 

female prostitute does about the vagina. To be brief, we shall 
state that any one of the following pathological conditions may 
be present as a result of intercourse per rectum, some produced 
as a result of direct contact, others by secondary infection : — 

1. Hard chancre. T. Condylomata (syphilitic 

2. Soft chancre (phagedenic or or gonorrheal). 

otherwise). 8. Fistnla. 

3. Proctitis (simple or gonorrheal). 9. Lacerations and abrasions. 

4. Ulceration. 10. Incontinence. 

5. Fissures. 11. Ecchymoses. 

6. Abscess. 12. Deformity of the anus. 

We shall not attempt to outline the treatment of these 
diseases in this connection, for the reason that the treatment of 
each has been given in detail in the other chapters of this book, 
to which we refer the reader. Before departing from this 
subject we wish to speak of one other habit through which 
diseased conditions about the rectum and anus are sometimes 
produced, — that of rectal onanism (masturbation). 

Rectal Onanism. 

Rectal masturbation is sometimes resorted to by those who 
are not permitted to have normal intercourse with women for 
various reasons. It is more frequently resorted to, however, by 
old men and younger ones who, from some cause, have lost their 
sexual power and cannot get satisfaction in the natural way. 
That sexual orgasm may be excited in this way there is little 
room to doubt. If such were not the case these people would 
not submit more than once to the pain and disgust that at first 
must accompany the act. On the contrary, it is a noted fact 
that, when once this habit is commenced, its victims seldom 
have will-power to quit it. That they must get some pleasure 
out of the intercourse is proved by the actions of those passive 
pederasts who are neither forced nor paid to submit to the 
active party, but, on the other hand, seek those who will gratify 
their desires and, if necessary, recompense them for taking the 



378 DISEASES OF THE RECTUM AND ANUS. 

active part. The instruments used ordinarily in rectal mastur- 
bation are the ringer, candles, bottles, walking-sticks, rectal 
bougies, and, in fact, anything that can be introduced into the 
rectum to excite sexual orgasm. 

There are a variety of pathological conditions that may be 
present about the rectum and anus as a result of this practice ; 
the most common of these, however, are injuries done to the 
mucous membrane, weakening of the sphincter muscle, and an 
inflammation of the rectum. In old habitues the mucous mem- 
brane, when not ulcerated and inflamed, is very much thickened, 
glistens, and looks not unlike parchment. We again refer the 
reader to the other chapters for the treatment of the diseases 
arising from this practice. 



CHAPTER XXXII. 

RAILROADING AS AN ETIOLOGICAL FACTOR IN 
RECTAL DISEASES. 

We wish now to invite your attention to a very common 
cause of rectal disease. We believe that railroading has never 
before been mentioned in any text-book on diseases of the 
rectum and anus. If we can show (and we believe we can) 
that the occupation of conductors, firemen, brakemen, and 
engineers predisposes them to rectal diseases, then all must 
agree with us that railroading is a cause of such afflictions. In 
the United States there are hundreds of thousands of men who 
earn their living by working on railway-trains. The subject, 
then, should enlist the interest not only of rectal specialists, but 
of all surgeons, and more especially those who are engaged in 
railway-work, for the reason that rectal diseases are so frequently 
found among railway-employes. 

During the last few years it has been our privilege to treat 
some hundreds of railway-employes for various rectal diseases. 
About three years ago it occurred to us that, perhaps, the 
occupation of these men might have something to do with 
causing the annoying conditions found so frequently about the 
terminal portion of the colon. Since this idea came to us we 
have given the subject much thought and have made extensive 
inquiries, both of employes and of railway-surgeons, to ascertain 
the proportion of said employes who suffer from some form of 
rectal disease, and their opinion as to whether or not their occu- 
pation predisposed them to these troubles. Our investigations 
lead us to believe that their occupation unquestionably plays an 
important part as a causative factor in these diseases, and, 
further, that 75 per cent., or even a larger proportion, of all 
railway-employes who have been running on trains for a term 

(379) 



380 DISEASES OF THE RECTUM AND ANUS. 

of five years or more suffer or have suffered from some disease 
about the rectum and the anus. Dr. W. P. King, the assistant 
chief surgeon of the Missouri Pacific Railroad Company, and 
his house-surgeon, Dr. G. F. Hamel, who have looked up the 
statistics, claim that my estimate is too small. This statement 
at first may appear startling, yet we feel confident that the ex- 
periences of " chief surgeons " will bear us out in this assertion. 
In talking this matter over recently with Dr. W. B. Outten, 
chief surgeon of the entire Missouri Pacific Railway System, and 
Dr. N. J. Pettijohn, chief surgeon of the Kansas City, Fort 
Scott, and Memphis Railway Company, both agreed with us as 
to the frequency of these diseases among railway-men. It is 
not our desire to be understood as stating that we believe 75 
per cent, of all the men who go to the railway-surgeon or to the 
hospital to be treated have some rectal trouble that requires 
immediate attention; but, on the contrary, — for we know that 
very few who enter the railway-hospital do so to be operated 
upon for rectal trouble alone, — to receive treatment for some 
disease — as typhoid fever, malaria, pneumonia, etc. — or for some 
accident that happened to them while in the discharge of their 
duties. In fact, not more than 10 per cent, of said employes 
undergo treatment for these diseases. There are several reasons 
to account for this. In the first place, these diseases are usually 
considered chronic and are sometimes contracted before the 
sufferer entered the railway-service or while employed by some 
other company. If such be the case it bars them from treat- 
ment at the company's expense; for they treat only those 
diseases contracted by the patient while in the employ of the 
road and of an accidental nature. In the second place, these 
diseases are usually considered of minor importance and are 
rarely inquired after by the surgeon in charge. In the third 
place, many employes believe them incurable ; others imagine 
that the treatment required to cure them is extremely painful 
and frequently followed by many complications. Hence, these 
sufferers do not make their afflictions known until after they 



RAILROADING IN RECTAL DISEASES. 381 

have had a profuse hemorrhage, suffered much acute pain, or 
had an obstruction of the bowel. 

It is with much pleasure, however, that we record the fact 
that, quite recently, two of the hospitals in the West — one in 
this city and one in St. Louis — have engaged a consultant on 
rectal diseases and are now offering relief to a class of sufferers 
who have heretofore been neglected ; and we predict that future 
statistics will show a much larger percentage of rectal trouble 
than those of the past, because of the fact that employes will 
soon find out how easily these diseases can be remedied by 
judicious treatment, and, further, because the rectal surgeon 
will be on the lookout for them. 

We wish to call your attention to the manner in which we 
think railroading brings about such pernicious results. 

In a general way, we think they are the outgrowth of 

1. Irregularities in living. 

2. Erect position assumed by employes. 

3. Irregular, jarring motion of the train. 

Irregularities in Living. 

When we come to study the habits and e very-day life of 
the average railway-employe, it is not such a difficult thing to 
understand why he is afflicted in this way. Certainly there is 
no other class of men who are more careless in their habits 
and manner of living than those under discussion. This is 
partly their fault and partly the fault of their occupation, 
which does not always permit of regular hours for sleeping, 
eating, exercising, and attending to the calls of nature. Con- 
sequently, when nature's laws are violated for any great length 
of time, an unnatural condition of affairs is brought about and 
some disease produced. Believing that many of these ailments 
are due directly or indirectly to the irregularities in sleeping, 
eating, attending to the calls of nature, and to dissipation, one 
or all combined, we will deal with these causes separately and 
in detail. 



SS2 DISEASES OF THE RECTUM AND ANUS. 

Irregularities in Sleeping. — All who are at all familiar 
with rail road- work know that a train-crew does not always 
have regular hours for sleep. One time the train is several 
hours late ; another time, when their run is completed and the 
men think that they are going to have a few hours' rest, they 
are sent out immediately with some other train, to take the 
place of some conductor, engineer, fireman, or hrakeman who 
is ill, or from some other cause. Again, many of these men 
do not have regular day- or night- runs, hut one that takes 
from thirty-six to forty-eight hours (Pullman conductors and 
porters). In the meantime they are deprived of sleep. All of 
us know from experience how the loss of sleep breaks one up 
and disturbs the system in general. At last, when trainmen 
reach the end of their run and have transacted any business that 
required their immediate attention, they eat something, and then 
many of them go to bed and sleep from eighteen to twenty-four 
hours or even longer, frequently remaining in a state of stupor 
not unlike that of a person who is under the influence of some 
strong narcotic. They do not take time to exercise, to talk to 
their families, or to do anything except to eat and sleep until time 
to go out on their next run. Others go to the opposite extreme. 
They take a short nap and devote the remainder of the time to 
dissipation and " doing the town " in general. All this is con- 
trary to the laws of nature. It interferes with the circulation, 
keeps the nerves in a high state of tension, and materially 
checks physiological digestion. 

Irregularities in Eating. — Irregularities in eating we be- 
lieve to be one of the most frequent causes of rectal diseases 
among railway-employes. Physiology teaches us that our 
meals, to be properly digested and assimilated, should be served 
at regular hours daily, that we should eat slowly and amid 
pleasant surroundings, and remain quiet and take very moderate 
exercise for an hour or so after each meal. Compare this 
physiological process with the manner in which meals are served 
to and partaken of by conductors, engineers, firemen, and 



RAILROADING IN RECTAL DISEASES. 383 

brakemen. The longest stop for meals at railway-stations is 
from fifteen to twenty minutes, part of this time being taken up 
by the respective duties of the crew. They run into the dining- 
room or to the lunch-counter and gulp down a quantity of 
food in ten minutes that should require at least half an hour or 
three-quarters, if it were properly eaten; then off they go at 
the rate of twenty or thirty miles an hour. Now, what is the 
result ] Food which has not been properly masticated or sali- 
vated is forced into a seaside stomach, or one that is being con- 
tinually rocked from side to side by the swaying motion of the 
train. An insufficient amount of gastric juice is secreted to 
grapple with large lumps of improperly-cooked meats, breads, 
vegetables, pastries, etc., under this excitement and constant 
turmoil. As a result, gastric digestion is materially interfered 
with. In time, however, the food, partly digested, is dumped 
into the small intestine, where, for similar reasons, incomplete 
intestinal digestion is the result. Finally it reaches the large 
intestine, where it may remain for a variable length of time, 
depending upon peristalsis and disposition and opportunity to 
empty the bowel. Owing to the rapid manner in which the 
food is taken and launched on its course through the alimentary 
canal, it would be impossible for the glands to secrete a suf- 
ficient amount of the digestive fluids to properly lubricate and 
digest it, even though the other surroundings were good. Con- 
sequently the feces contain much less fluid than they should 
when the lower portion of the colon is reached, and they are 
prone to collect in large quantities which cannot be moved by 
peristaltic action. The mucous membrane soon loses its sensi- 
tiveness, the glands refuse to secrete, and obstinate constipation 
of the worst form is the result. 

Irregularities in Attending the Calls of Nature. — It is a 
recognized fact that many railway-men suffer from obstinate 
constipation and its many evil consequences as the result of 
the irregular manner in which they respond to nature's demand 
and refuse to expel the excreta. Frequently they defer an action 



384 DISEASES OF THE RECTUM AND ANUS. 

from hour to hour or from one day to another, sometimes 
through gross carelessness on their part, at others to the fact that 
their- duties will not permit them to take sufficient time to 
empty the howel, and the act is postponed until a more suitable 
time. 

To enjoy perfect health every one should have at least one 
action daily, and physiology teaches us that the feces collect in 
the lower portion of the sigmoid and the rectum and remain 
there until shortly before stool, when peristalsis commences and 
they are moved downward into the rectum. Then the desire to 
go to stool is felt. If this warning of nature of the approach of 
the feces is appreciated and the contents of the rectum promptly 
expelled, all is well. On the other hand, when this hint is 
ignored, reverse peristalsis returns the feces upward into the 
sigmoid, where they remain until they are again propelled into 
the rectum, causing the sensation just referred to. Now, if 
this, like the previous one, is ignored, the mucous membrane 
soon loses its sensitiveness, the muscular coat its tonicity, and 
large quantities of fecal matter may accumulate in the sigmoid 
and the rectum without causing the least desire to go to stool. 
Many persons do not have more than one action a week, and 
not a few oftener than every two weeks. In fact, we have met 
very few, if any, railway-men who did not suffer to a greater or 
less extent from obstinate constipation. 

Dissipation. — It is a deplorable fact that a great many rail- 
way-employes are given to dissipation and drink large quan- 
tities of alcoholic stimulants, which unquestionably predispose 
them to rectal disease on account of the dilated and weakened 
condition of the blood-vessels which follows. 

Taken altogether, the irregularities of living of those who 
follow railroading tend to produce a sluggish condition of the 
circulation, of peristaltic action, and of the secretory glands and 
organs. These conditions result in not only local, but general, 
systemic disturbances as well, and are invariably aggravated by 
constipation, which is unquestionably the most frequent of all 



RAILROADING IN RECTAL DISEASES. 385 

known causes of rectal diseases. Any one of the following 
diseases of the rectum and the anus may be caused by it. 

The diseases to be named have been previously mentioned 
in the chapter on " Constipation," but we beg to review them 
again, since they bear directly upon the topic now under 
discussion. 

Hypertroplded Sphincter. — When an action has been de- 
ferred for several days the feces accumulate, the watery portion 
is absorbed ; they become dry, hard, nodular, and act as an irri- 
tant, exciting the sphincter muscle to a state of chronic contrac- 
tion, and it becomes strong and hypertrophied. 

Anal Fissure. — On account of the hardened condition of 
the feces they are very difficult to expel, oftentimes making a 
rent in the bowel at the muco-cutaneous junction that in time 
becomes an irritable fissure. 

Ulceration. — Ulceration of the rectum and the sigmoid is a 
frequent symptom of persistent constipation, because of pressure 
on the nutrient blood-vessels by the fecal mass, causing a necrosis 
of the tissues. 

Hemorrlioicls. — Constipation is productive of hemorrhoids 
in several ways : first, because of obstruction to the return-flow 
of venous blood ; secondly, because of venous engorgement of 
the hemorrhoidal veins during the violent and prolonged strain- 
ing every time there is an action ; thirdly, because of the general 
laxity of the tissues in those suffering from constipation. 

Prolapsus. — A prolapsus of the mucous membrane may be 
the result of a fecal mass's pushing it down in front of it when 
an action occurs ; again, it may be the result of a paresis of the 
bowel caused by pressure on the nerves by the mass. 

Proctitis and Periproctitis. — An inflammation of the 
rectum and the surrounding tissues that may or may not termi- 
nate in an abscess and fistula is frequently caused by consti- 
pation, as a result of injury to the very sensitive mucous mem- 
brane by the hardened feces, and, further, from the fact that the 
feces, when long retained, undergo decomposition and expose 

25 



3$6 DISEASES OF THE RECTUM AND ANUS. 

any unsound portion of the membrane to the many septic organ- 
isms contained therein. 

Neuralgia and Coccygodynia. — The fecal mass within the 
sigmoid sometimes presses upon the neighboring- nerves, causing 
reflex pains to be felt in the region of the sacrum and coccyx. 
Such pains are usually diagnosed as neuralgia of the rectum 
and coccygodynia. 

In addition to causing the diseases just enumerated, con- 
stipation will aggravate any other disease of the rectum or colon 
that might be present. 

Having demonstrated that constipation is very often pro- 
duced by irregularities in living by those who follow railroading 
as a livelihood, and, further, that it plays a very important part 
in the etiology of rectal diseases, we now invite your attention 
to other causes which are of equal importance from an etiological 
stand-point, and about which nothing has been written. 

Erect Position. 

Trainmen, as a rule, are required to spend the major por- 
tion of their time while on duty in the erect or semi-erect 
position. This, we believe, plays an important part in causing 
rectal diseases. The dilatation of the rectal veins induced by 
gravity, the shaking motion of the train, and the fact that the 
rectal veins have no valves to support the column of blood are 
to be considered. That able teacher and most excellent sur- 
geon, Van Buren, once said, in discussing the etiology of hemor- 
rhoids, that the erect posture assumed by man undoubtedly 
played an important part in causing that disease, and cited the 
fact that quadrupeds never suffer from a similar condition. All 
surgeons must have noticed the frequency of varicose veins of 
the lower extremities in clerks and others whose duties compel 
them to be on their feet. The same can be said of railway- 
employes. We believe we are warranted in going a step farther 
in claiming that, for the same reason, we may have a dilatation 
not only of veins of the lower extremities, but of the large 



RAILROADING IN RECTAL DISEASES. 387 

veins about the rectum, that sooner or later end in hemorrhoidal 
disease, ulceration, etc. 

Irregular, Jarring Motion. 

We believe that the irregular, jarring motion of the train 
well deserves a place as an etiological factor in these diseases 
among railway employes. Unquestionably it tends to pro- 
duce a congestion of the rectal veins similar to that seen in the 
lower extremities. In making this assertion we not only have 
the experience of chief surgeons and employes, but our own 
personal experience. We have frequently noticed that, when 
riding on the train for several hours, our feet would become 
swollen while sitting in the upright position or semi-prone when 
in a chair-car. If we chanced to take off our shoes at night, 
in the morning we could get them on only with great difficulty. 
Now, it seems to us that, if the position and jarring motion 
of the train would produce this congestion of the veins of the 
lower extremities in so short a time, it is easy to understand 
how we might find a permanent congestion of the venous 
plexuses about the rectum and anus (especially since these veins 
have no valves) in those whose duties compel them to spend 
the greatest part of their time on the train. This condition, in 
conjunction with the constipation induced by the irregularities 
of their manner of living, unquestionably predisposes them to 
numerous diseases found in this locality. For a similar reason 
commercial travelers are frequently afflicted with rectal diseases. 
Also employes in factories, where they are required to be on 
their feet and the floors are in a constant motion as a result of 
ponderous machinery. 

To show the proportion of rectal diseases to all others 
treated by the railway-surgeon, and also the proportion of the 
various rectal diseases to each other, we append the following- 
tables, which represent no slight amount of labor on our part. 
In this connection we wish to extend our sincere thanks to Dr. 
W. B. Outten, of St. Louis, for kindly placing the statistics at 



388 



DISEASES OF THE RECTUM AND ANUS. 



our command and. further, for the untiring energy displayed by 
him in going over them with us. 

We also suggest that, if many of the managers of public 
hospitals would display a similar amount of system in keeping 
the record of cases as has Dr. Outten and Dr. King, it would 
only be a few years until valuable statistics could be collected 
showing the frequency of rectal and other diseases; but as they 
are kept at present in many of these institutions the records 
are valueless. 

Table No. 1. — Analysis of One Hundred and Seventy Thousand Cases.* 



[Treated in the hospitals of the Missouri Pacific Railway System from 1884 to 18 
showing the proportion of rectal diseases.] 


H, 


Hospitals. 


o 


o 

CO 

a 

o 
u 


CO 

'o 
o 

s 

3 


o 
o 


3 

CO 


9 

B 

CO 
CO 


CO 

S3 

CO 

p 


CO 


e3 

'Jc 

CD 


if 


m 
co 

CD 

o 

CO 

< 


o3 

H 

a 

o 

-a 

c 
O 


s . 

S3 <D 

1.2 


3 

o 


Total Number 

of Rectal Cases 

Received. 


Total Number 

of All Cases 

Received. 


Fort Worth . J 
Marshal .... 
Sedalia . . . . < 

Palestine . . . < 

Kansas City . < 
All hospitals . . 
St. Louis . . . < 


1886 

to 
1X89 
L886 
1886 

to 
1888 
1886 

to 
1889 
1888 

to 
1894 
1885 
[885 

to 
1894 


200 
177 
1294 

153 

1580 
924 

2745 


67 

40 

296 

95 

658 
125 

nil 


3 
5 
4 

9 

24 

11 

239 


14 
5 
4 

35 

72 

9 

110 


3 

2 

9 

3 

2 
42 


1 

3 

1 

2 

2 

7 

24 


12 

26 

20 

59 

18 

206 


8 
149 


2 
3 

2 

13 
11 

28 


7 


1 


i 
i 

2 


1 

3 
3 


297 
236 
1631 

327 

2414 
1115 
46G6 


7882 
4068 

7485 

7397 

4181 
20629 
118928 


Totals .... 




707.'! 


2392 


295 


249 


61 


40 


341 


157 


59 


7 


1 


4 


7 


10686 


170570 









Total number of cases treated in hospitals 170,570 

Total number of eases of rectal diseases 10,656 

Percentage of rectal diseases 6.4 

When we come to study the above table closely we learn 
some very interesting facts regarding the frequency of the va- 
rious rectal diseases to each other. These differ very materially 
from those given by Allingham, Cooper, and others who 
attempted to group these diseases. If we leave out those cases 



* This table has been compiled from statistics kindly placed at my disposal by Dr. W. B. 
Outten, of St. Louis, Chief Surgeon of the Missouri Pacific Railroad Company. 



RAILROADING IN RECTAL DISEASES. 389 

diagnosed as " enteritis " and "enteralgia," which properly do 
not belong in a work of this kind, we still have 10,188 cases 
of rectal and anal diseases, and we find that nearly every dis- 
ease found about the rectum and anus is represented. In point 
of frequency constipation heads the list ; more than two-thirds 
of the entire number — 7073 — entered the hospital to get relief 
from their constipated condition. Next comes hemorrhoids, with 
2392 cases, comprising almost one-fourth of the entire number. 
Then ulceration, with 295 cases. Next, fistula, with 249; while 
the other diseases occur much less frequently. Here we have 
the usual order of things reversed, for in Allingham's analysis 
of 4000 cases of rectal disease treated at St. Mark's Hospital, 
London, he treated one-third more fistulas than hemorrhoids. 
It must be remembered, however, that this institution has a great 
reputation for the cure of fistula, and, further, that fistula is 
found much more frequently in charitable institutions than in 
hospitals where patients pay their own way. Another reason 
why railway-men are more frequently afflicted with hemorrhoids 
than with fistula is because of the dilated condition of the rectal 
veins, induced by habits, the erect position, and irregular, jar- 
ring motion of the train. In fact, in our practice, both private 
and dispensary, we have been called upon more frequently to 
treat hemorrhoids and ulceration than fistula. Other surgeons 
in this country with whom we have discussed this subject have 
had a similar experience. 

TVe wish just here to append Table No. 2, which gives 
a synopsis of our work in rectal and anal surgery for one 
year, 1893-1894, at the Kansas City, Fort Scott, and Memphis 
Railroad Hospital, for which Dr. N. J. Pettijohn is chief 
surgeon. In round numbers 800 patients were treated during 
this time. Of this number 30 entered the hospital purposely 
to be treated for some rectal disease. Many of the other 
patients had rectal disease, but considered it of secondary im- 
portance to the disease or accident which was the immediate 
cause of their entering the hospital. 



390 



DISEASES OF THE RECTUM AND ANUS. 



H 




O 


-0 

'P jD 




CD Ch 
0.1 




J 


-p -d -r -a" 


~'~-p* 'd'd'd -d'g = -f-'~-p' 


. o'P — — -P -a 


d 


-d -d 'd-d -d-d 


£ 


<d .- oj « 


9 V S Si <U CU CD r J CD CD CD <B 


^ . O <D CD CD CD 


9 


O . 


qj ^j qj £> o^ a^ 












PS 


a r 3 3 


555 555 5 a — 5555 


:- P P p p P P 


P 


.a s 


p p p 5 p p 




_ _ . 


OO^ UOi U-> OtJOO 


O 


fe° 


O QJDUU 






s 








co 


i> Be 

: - 

gS 

-: 




ID OD EC *S 


CO CO 






- co' >~t 
2 wr = CD >-> V 


CO 

OB EO g « 

Sits 

- " Z © 


£»* 15 coo a«a» § 

p^5 »??<» >^2oi'i'5 
op" o-o -J jg cd «d ^ *o o 

£§§ -c.5 S.iL^-S** 


•51 « . . » p* 

tD w J J M CD 
CD P ? ^ £ CD 

I |p2§ 1 


to 

A) 

CD 
O 


CO 

>> 

CD 




x/.hh 


CCfaO hiH HW HHtfH 


H HOOH H 


H 


EH 


W HcotzifciaQ 




>. 2 if 


■3= .B * * 

o3 a - <» • S 

0)p oi CD -^ 


a CD 'P ^' O Tj" 

.co s £ -g cct; 


O 
'o 


ft 

s'a 


M 

CD 

_p 




5 a" CD 


£ « ^tM P «W 

.— " co o ci C 
M ^ M a 
o^ o a .3 c 

*2 *! C eS +3 +3 

1 i|*i 11 .1 1 

ce *^.2|-d S S .2p .£ 

S a r"^ - ^ * ^ S cd c 5 "^ cd = 

^ 3 l 5 OD« XS S CD -S-^ 

2 = t: x = .-5 x 5 -3 =i 5 '5 § S > 
5oH c^^;5 53 M^iofi 


S^s 


^r«^ 


o 

H 

a 
w 
a. 

O 

a 
o 

H 

W 

a 

t- 

H 


p M>c8 

8S5 

-a . = 
S o S 

^ cc > 

P-" 
u to® 

£S|f 

° 5 o-a 
-3 cuH * 

3 Pi— ^ 
~'P 2 I 
ft£ 2^- 

P co CD CD 

lares 


li I !?s.a 

sin > B g|* 

co »3 •- c 2 -" 

fl 3 * r,' M C^OS 

Sl®.§5 .'^°^2 

S 5 = rf ppp5~S 

g " co Ct| ai 05 ^ C 


c'Lo'cS 

p-: p 
^ art 

a §*£ 

C8 >,« 
jo -3 t) 

-' Sr^.p 

So^-g, 

S-2^ 1 " 
5'Ss'g 

to c ° 

S.2»'o . 


CD <» O 
P 2 1 

5a g 

CD CD lp 

pS a, 

§g c^ 
ftO ^ 

a t> a 
gad c« 

|2.2 .cd 

^ co >>J5C 

cd« p S a a 

%,'Z cd a o cd 3 
>2 g ^'^ Sj 

g o &Cce^ Mg 




dehwc 


W pp5^ o 


A 


« 


P5 35pJic 




o 




si 

p 








. 


CO 

0) . 


o g prt fl« 

.2 5 S go oS o 


"S 








1 

-«1 


MM 


+3 

CO 

o 








O 

a. 
% 


O 

CO 








.2 - - a 


cc"3 c5S .22S'5c1oc^ 


+3 
CO P 

S • • -p • 

P CD CD CD p, CD 

A ooc2 o 


2 


CD 

P 


CO 

.li 

cd ajrt p cd' cd 
o o?|oo 




««|309 


o 


O 




SooP 


O^i^ fe55Z5> PO S^^H 


CU £££fc fc 


S5 


fe 


fc !z;PHfe^^ 


CO 

0} 

O 

ss 

Q 


S CO 

•a o 
*»'•£ 2 

E ~2 

» p . _• 

- — s " 


/ - ° 3 § © 

Hi isg.»l&«4s 

® ^=!P »e3 <D 5..S^O-g i g§ 
h "3 « e§2bSS , d t oi»^2 


P X nj CO 

Pj-Pco ,3 «« 
p O "3 • • a <» 

13 "S cd S » cd 

-2 2S'= = d S 

P.S CD i- ^ _ 
S^i)S»g CD 

■ r 5 - x p .2 > 


5 

s 

u 

e3 

CO 


co -a 

a -d S ,22 co" 
§•2 2 2 3 
ta^ p 2 S 
tig. -a fj .a 

w ^ a~ s p p « 

Cl> • «8-S PP«co 

jp o a 






bs § -^ g55S2<»J'S2Vc8 i g 




CD 




:Jo • cS ftce cd 




sill 

CD fl Q «H 




■a 5 g S « -5 gj 

co.--*Jcoa,2 x^ 


co 


S?f-|§ < a'Si£in'3i 

!m S 0,*P CD '"'CD ^ CD P 

eSaocoS^'o-gS-gS 




3D £ A Ph 


^HS SShH h> 33Afc 


S ^Spp si 


Jh 


§ 


^ cu£^£^ 




— " 

CD 

.3 


2 65 

p | ^3 










fc 


w P 










o 


<j H 




CD * 










rf c9 . 


5 g ^ P ^ jj 


4J . CO 








B. 

O 


a, a a 

>0 £ -r. 9 


° <n 5 ^ ^ c • ^ 


3 S«'l • ^ 

a = cd 2 <u s 


P 


CD 
CD 


a s ^ s s s 

cd :- P j- p - 
^1 CP C « O 


go§>§ 


MOO -^ - - ^ Sf Ofii? 


d ® = — ^ .° 


P 


.P 


§^■3 ic "5 §i|§^aS 


- ^ - C rt CD 


£ 


M 


a! P3 PP5 P^ 2 

t- cs o cj.a ce 




H--C 


cgjp ^ehJ oM oJWa 


H Ki'.J x 


£ 


1 


cq JoJ&hP 




3388 


se s — — -. i /• so o cc::-i 


M — CC-rco CI 


cc 


§5 


CM HOMffiH 
CO CO-fiCOCNCO 


"\- 


— -!-■: — 


■ -■-I- f t. o --I'M eo ■* ui <n 


1 - / r. - — i T 1 


S3 


CI 


>C 'OI-'X'CJSO 
CI CI CI CI CM CO 



RAILROADING IN" RECTAL DISEASES. 391 

We include this table for the reason that it gives in brief 
the pei' _ rectal to all other diseases, the age. the di _- 

nosis. the complications, the treatment or operation, the ler_ 
of time under treatment of each patient, and shows the very 
_e percentage of the - that can be easily and speedily 

cured when given that amount c ntion that they should 

have in e aulway-hospit 



INDEX. 



Abscess, 68 

ischio-rectal, 68 
treatment, 69 

marginal, 70 
treatment, 70 

where found, 74 
Allingliam, Herbert, on cancer, 291 

method of excision, 300 

on colotomy, 308 
Allingham's (Sr.) analysis of 100 cases 

of stricture, 151 
American operation for hemorrhoids, 211 

as a cause of stricture, 149 
Anal fistula, 72 

fissure, 111 
Anatomy of rectum and anus, 3 
Andrews, on solution for hemorrhoids, 

205 
Anesthetics, in examination, 24 

in operating on tubercular fistula, 103 
Anus, 8 

fistula, 72 

malformations, 28 
symptoms of, 29-37 
treatment, 29-37 
varieties of, 28 

syphilitic affections, 62 
Arteries of rectum, 6 

inferior hemorrhoidal, 6 

middle hemorrhoidal, 6 

superior hemorrhoidal, 6 
Artificial anus, 359 

closure, 359 
Author's artificial light, 26 

pile and polypus clamp, 221 

report of 250 cases of constipation, 265 

solution for injecting piles, 206 

table of cases of stricture, 152 
Auto-infection, 268 



bibliography, 290 

colon bacillus, 278 

effect upon circulation, 274 

effect upon nerves, 275 

effect upon respiration, 274 

Park's (Dr.) letter, 283 

treatment, 287 

Welch's (Dr.) letter, 285 

Bacillus coli communis, 278 

Bougies in stricture, 169 

Brinkerhoff's prescription for injecting 

piles, 205 
Bulkley's prescription for pruritus ani, 

238 
Byrd's case, 39 

Cancer, 291 
forms of, 292 
recapitulation, 306 
symptoms, 294 
treatment, 295 
palliative, 295 
surgical, 296 

after-treatment, 305 

Allingham's (Herbert) method, 

300 
excision of rectum, 297 
Kraske's operation, 299 
modification of, 304 
Helm's modification, 305 
Colotomy, 308 
anatomy, 318 
left inguinal, 318 
lumbar, 321 
right inguinal, 318 
transverse, 325 
choice of operation, 311, 315 
conditions necessitating, 311 

(393) 



394 



INDEX. 



Colotomy, inguinal, 326 

important suggestions, 338 

action of bowels, 343 
length of mesentery, 338 
prolapse, or procidentia, tkroug 

opening, 340 
spur, 339 
left inguinal, 326 
right inguinal, 343 
supplementary operation, 332 
introduction, 308 
lumbar, 344 

prolapse after, 353 
right lumbar, 356 
spur, 353 
transverse, 357 
Condylomata, syphilitic, 62 
Constipation, 10, 253 
as a cause of rectal disease, 256 
etiology, 253 
symptoms, 255 
treatment, 257 
abdominal massage, 260 
author's report of 250 cases, 265 
dilatation, 259 
electricity, 263 
non-medicinal method, 258 

steps in, 258 
rules patient must follow, 263 
warm -water injections, 262 
Cripps, 70 cases of stricture, 151 
Cripps, mortality of malformations, 39 

Diagnosis, of diarrhea, 247 
of fissure, 119 
of hemorrhoids, 183 
of stricture, 161 
of ulceration, 137 
Diarrhea, 17, 241 

symptom of chronic catarrh, 242 

of impaction of feces, 244 

of malignant stricture, 243 

of polypi, 244 

of prolapsus, 244 

of rectal disease, 17, 242 

of ulceration, 243 

of villous tumors, 244 
character of the stools, 215 
diagnosis, 247 



Diarrhea, illustrative cases, 251, 252 
in ulceration, 135 
pathological anatomy in, 244 
prognosis, 248 
remarks on, 241 
symptoms, 245 
treatment, 248 

Electrolysis in stricture, 170 
Etiology of hemorrhoids, 182 
Examination of rectum and anus, 19 

by artificial light, 26 

by introduction of hands, 27 

by palpation, 21 

digital, 21 

position for, 19 

remarks on, 19 

under anesthesia, 24 

visual, 20 

Fecal fistula, 359 
causes, 359 
treatment, 359 
Fecal impaction, 266 
symptoms, 266 
treatment, 267 
Feces, 18 

characteristics of, 18 
incontinence, 106 
significance of, 18 
Fissure, 111 
causes, 114 
diagnosis, 119 
differential diagnosis, 119 

from blind internal fistula, 120 

from disease of neighboring organs, 
120 

from hemorrhoids, 119 

from neuralgia, 119 

from sphincteric contraction, 120 
examination for, 117 
history, 111 
illustrative cases, 128 
prognosis, 121 
stages, 113 
symptoms, 115 

bleeding, 116 

flatulence, 116 

pain, 115 



INDEX. 



395 



Fissure, treatment, 121 
operative, 125 

after-treatment, 127 
cauterization, 125 
dilatation, 125 
division, 127 
excision, 127 
palliative, 123 
Fistula, 72 
after-treatment, 92 
definition, 73 
diagnosis, 81 

general remarks on, 72, 79 
history of, 72 
illustrative cases, 94-98 
prognosis, 94 

relation to phthisis pulmonalis, 99 
symptoms, 80 
treatment, 82 
operative, 82 
dilatation, 83 
division, 85 
excision, 88 
fistulatome, 88 
injection, 83 
ligation, 84 
resume, 91 
tubercular, 99 

after-treatment, 104 
illustrative cases, 104 
prognosis, 101 
symptoms, 100 
treatment, 100 
use of chloroform, 103 
varieties, 99 
varieties of, 74 
blind external, 76 

treatment, 89 
blind internal, 75 

treatment, 89 
complete, 74 
complete external, 76 

treatment, 89 
complete internal, 76 

treatment, 89 
horseshoe, 77 

treatment, 90 

recto-urethral, 79 

treatment, 91 



Fistula, varieties of, recto-vaginal, 77 
treatment, 90 
recto vesical, 78 
treatment, 91 

Green's solution for injecting hemor- 
rhoids, 205 
Growths, non-malignant, 54-61 
Gum mat a, 62 

Hemorrhage, in rectal diseases, 15, 229 
from fissure, 15 
from internal hemorrhoids, 15 
from malignant disease, 16 
from polypi, 16 
from prolapsus, 15 
from stomach, 16 
from stricture, 16 
from ulceration, 16 
from villous growths, 16 
from wounds and foreign bodies, 16 
methods of arresting, 231 
post-operative, 229 
primary, 229 
recurrent, 230 
secondary, 230 
Hemorrhoidal clamp, author's, 221 

advantages claimed for, 221 
Hemorrhoids, 180 
after-treatment, 224 
classification, 181 
differential diagnosis, 183 

from hemorrhage, 184 

from malignant growths. 184 

from polypi, 184 

from prolapsus, 184 

from pruritus ani, 184 

from venereal warts, 184 

from villous tumors, 184 
etiology, 182 
external, 185 

definition, 181 

illustrative cases, 188-190 

treatment, 186 
operative, 187 
palliative, 187 

varieties, 185 
cutaneous, 186 
symptoms, 186 



396 



INDEX. 



Hemorrhoids, external, varieties, throm- 
botic, 185 
symptoms, 180 
history, 180 
illustrative cases, 226 
internal, 191 
definition, 181 
symptoms, 191 
treatment, 194 
by chemical caustics, 197 
by injection method, 201 
cases suitable for, 203 
history, 202 
preparation for, 204 
report of case, 206 
rules to follow, 204 
solutions used, 205 
author's, 206 
Brinkerhoffs, 205 
Green's, 205 
Kelsey's, 205 
Rorick's, 205 
Yount's, 205 
by ligature, 211 
history, 211 
pain following, 214 
results, 215 
steps taken, 212 
cauterization, 199 
galvano-cautery, 201 
linear, 200 
puncture, 200 
clamp and cautery, 216 
after-dressing, 218 
author's clamp, 221 
advantages of, 221 
history, 216 
steps in operation, 217 
time saved, 219 
crushing, 198 
dilatation, 199 
ecraseur, 197 
operative, 196 
palliative, 194 
preparation for, 196 
retention of urine, 225 
submucous ligation, 223 
surgical, 195 
Whitehead's operation, 208 



Hemorrhoids, internal, treatment, White- 
head's operation, advantages 
of, 210 
criticisms on, 210 
varieties, 192 
capillary, 192 
venous, 193 
prognosis, 184, 225 

Impaction of feces, 266 

symptoms, 266 

treatment, 267 
Incontinence, 106 

causes, 106 

treatment, 108 

by cauterization, 108 
bj r plastic operation, 109 
illustrative case, 109 
Inflammation, erysipelatous, 71 

gangrenous, 71 

of rectum, 65 
Injection, in hemorrhoids, 201 

hemorrhoids suitable for, 203 

report of case, 206 

solutions used, 205 
Injuries of rectum, 362 

treatment, 365 
Introduction, 1 
Invagination, 45 
Ischio-rectal abscess, 68 

symptoms, 69 

treatment, 69 
Itching piles (pruritus ani), 235 

Kelsey on injection in hemorrhoids, 205 

Lymphatics, 7 

Malformations of rectum and anus, 28 
imperforate anus, 28 

symptoms, 29-37 

treatment, 29-37 

varieties, 28 
imperforate rectum, 37 

symptoms, 37 

treatment, 38 

varieties, 37 
mortality in 100 cases, 39 
Marginal abscess, 70 



INDEX. 



397 



Muscles of rectum, 8 
external sphincter, 8 
internal sphincter, 8 
levator ani, 9 
recto-coccygeus, 9 

Nerves of rectum, 7 
Neuralgia of rectum, 366 
treatment, 368 

Onanism, rectal, 377 

Pain, characteristics, in rectal disease, 12 

following clamp-and-cautery operation, 
218 

following ligature operation, 214 

in fissure, 12, 115 

in hemorrhoids, 12 

in internal hemorrhoids, 13 

in malignant disease, 13 

in ulceration, 13 

varieties, 12 
Papillomata, 60 

treatment, 61 
Paquelin cautery, 216 
Park's (Dr.) letter 283 
Pederasty, 372 
Periproctitis, 65 

symptoms, 69 

treatment, 69 
Phthisis pulmonalis, relation to fistula, 

99 
Piles, 180-227 
Polypi, 54 

adenoid, or soft, 55 
treatment, 56 

disseminated, 58 

fibrous, or hard, 56 
treatment, 58 

illustrative cases, 59 
Position for examination, 19 
Proctitis, 65 

acute, 65 

chronic, 65 

prognosis, 67 

symptoms, 66 

treatment, 68 

varieties, 65 
diphtheritic, 67 



Proctitis, varieties, dysenteric, 66 

gonorrheal, 67 
Proctotomy, in stricture, 172 
Prognosis, diarrhea, 248 

fissure, 121 

fistula, 94 

hemorrhoids, 184, 225 

painful ulcer, 121 

stricture, 164 

tubercular fistula, 101 

ulceration, 138 
Prolapse, illustrative cases, 51-53 

of all rectal coats, 43 

of mucous membrane, 42 

of rectum and anus, 41 

of upper into lower portion of rectum, 
45 

remarks, 41 

treatment, 46 
operative, 49 
palliative, 47 

varieties, 41 
Protrusions, in rectal disease, 14 

internal hemorrhoids, 14 

polypi, 14 

prolapsus, 14 

varieties, 14 

villous tumors, 15 
Pruritus ani (itching piles), 235 

etiology, 235 

report of case, 240 

symptoms, 236 

treatment, 236 
Bulkley's prescription, 238 
surgical, 239 
Pus, as a symptom of rectal disease, 18 

Railroading, as a cause of rectal disease, 
379 

synopsis of 30 cases, 390 

table of 170,000 cases, 388 
Rectal discharges, 241, 251 

onanism, 377 
Rectum, 3, 10 

arterial supply, 5 

cancer, 291 

coats, 3 

curves, 3 

fistula, 72 



898 



INDEX. 



Rectum, inflammation, C5 

length, 3 

lymphatics, 7 

malformations, 28, 37 

mucous membrane, 5 

muscles, 8 

muscular, 4 

nerves, 7 

neuralgia of, 386 

peritoneal, 4 

physiology, 10 

prolapsus, 41, 53 

syphilitic affections, 62 

veins, 6 

wounds and injuries, 366 
Rickett's (Dr. Merrill) submucous liga- 
tion of hemorrhoids, 223 
Ro rick's solution for hemorrhoids, 205 

Sodomy, 372 
Speculums, 23, 25 
Stomach, 16 

Stricture, appearance of anus, 160 
author's table of cases, 152 
benign, 146 
classification as to form, 147 
etiological classification, 147 
catarrhal, 153 
other forms, 154 
congenital, 154 
muscular bands, 154 
inflammatory, 155 
spasmodic, 155 
syphilitic, 150 
traumatic, 147 
i ubercular, 153 
Cripps's table of cases, 151 
diagnosis, 161 
differential diagnosis, 163 
malignant, 163 
non-malignant, 163 
general remarks, 147 
illustrative cases, 175-179 
pathological anatomy, 156 
prognosis, 164 
symptoms, 157 

character of the stool, 158 
complications. 160 
peritonitis, 160 



Stricture, symptoms, recapitulation, 160 
treatment, 165 
operative, 167 
by dilatation, 167 
bougies, 169 
dilators, 169 
forcible, 167 
gradual, 167 
colotomy, 174 
electrolysis, 170 
excision, 174 
internal incision, 171 
report of case, 171 
posterior proctotomy, 172 
advantages, 172 
report of case, 173 
palliative, 165 
Symptomatology, 12 

remarks, 12 
Syphilitic affections, 62 
condylomata, 62 
congenital syphilis, 63 
gummatous, 62 
treatment, 63 

Table, operating, 20 

Ulcer, 111 
diagnosis, 119 
painful, 111 
prognosis, 121 
symptoms, 115 
treatment, 121 

operative, 125 

palliative, 123 
Ulceration, 130 
causes, 130 
classification, 130 

catarrhal, 133 

dysenteric, 13? 

lupoid, ?33 

rodent, 134 

syphilitic, 131 

traumatic, 131 

tubercular, 133 
varieties, 133 
diagnosis, 137 
illustrative cases, 143-145 
prognosis, 138 



INDEX. 



399 



Ulceration, symptoms 
diarrhea, 135 
discharges, 137 
hemorrhage, 136 
itching, 137 
other, 137 
pain, 135 
treatment, 138 
operative, 141 
palliative, 138 

Urethral fistula, 79 
treatment, 91 



135 



Veins of rectum, inferior hemorrhoidal, 6 Yount on injection in hemorrhoids, 205 



Veins of rectum, middle hemorrhoidal, 6 

superior hemorrhoidal, 6 
Villous tumors, 59 

treatment, 60 

Welch on pathogenic action of colon 

bacillus, 280 
Welch's letter, 285 
Whitehead's operation in piles, 208 
Wounds of rectum, 362 
treatment, 365 



OCTOBER, 1895 



Catalogue of the Publications 

of 

THE F. A. DAVIS CO., 
/Wedical Publishers $ FJ°°ksellers, 

1914 and 1916 CHERRY STREET, 

PHILADELPHIA, PA. 



Branch Offices: 

NEW YORK CITY 117 W. Forty-Second Street. 

CHICAGO.— 9 Lakeside Building, 214-220 S. Clark Street. 

F. J. REBMAN, 11 Adam St., Strand, W.C., London, Eng. 

Order from Nearest Office. 

For Sale by All Booksellers. 



Prices of books, as given in our catalogue or circu- 
lars, include full prepayment of postage, freight, or 
express charges. Customers in Canada or Mexico must 
pay the cost of duty, in addition, at point of destination. 

We do not hold ourselves responsible for books sent 
by mail ; to insure safe arrival of books sent to distant 
parts, the package should be registered. Charges for 
registering (at purchaser's expense), 8 cents for every 
four pounds or less. 

N.B. — Remittances should be made by Express Money-Order, 
Post-Office Money-Order, Registered Letter, or Draft on New 
York City, Philadelphia, Boston, or Chicago. Money sent in any 
other way must be entirely at risk of sender. 



Medical Publications of The F. A. Davis Co.. Philadelphia. 



Louis, Mo. 230 pages. 12mo. Extra Cloth. This volume is one of a series 
of three. The other two, treating of "Syphilis in the Middle Ages" and 
* Syphilis in Modern Times," are now in Press and will he published at an 
early day Net, $1.35 

CAPP— The Daughter. 

Her Health, Education, and "Wedlock. Homely Suggestions to Mothers 
and Daughters. By William M. Capp, M.D., Philadelphia. 12mo. 150 
pages. Attractively bound in Extra Cloth. Net, $1.00. In Paper Covers 
(unabridged) Net, .50 

CATH ELL— Book on the Physician Himself. 

And Things that Concern his Reputation and Success. By D. "W. 
€athell, M.D., Baltimore, Md. Tenth Edition. Author's last revision. 
Royal Octavo. About 350 pages. Extra Cloth Net, 2.00 

CLEVENGER— Spinal Concussion. 

Surgically Considered as a Cause of Spinal Injury, and Neurologically 
Restricted to a Certain Symptom Group, for which is Suggested the Designa- 
tion " Erichsen's Disease," as one form of the Traumatic Neuroses. By S. V. 
Clevenger, M.D., Consulting Physician, Reese and Alexian Hospitals ; 
Late Pathologist, County Insane Asylum, Chicago, etc. Royal Octavo. 
Nearly 400 pages. With 30 Wood-Engravings Net, 3.50 

COLTMAN— The Chinese : Their Present and Future. 

Medical, Political, and Social. By Robert Coltman, Jr., M.D., Sur- 
geon in Charge of the Presbyterian Hospital and Dispensary at Teng Chow 
Fu, etc. Fifteen Fine Engravings on Extra Plate Paper, from photographs 
of persons, places, and objects characteristic of China. Royal Octavo. 212 
pages. Extra Cloth, with Chinese Side-Stamp in gold Net, 1.75 

DAVIS— Diseases of the Lungs, Heart, and Kidneys. 

By N. S. Davis, Jr., A.M., M.D., Professor of Principles and Practice 
of Medicine, Chicago Medical College, etc. 12mo. Over 300 pages. Extra 
Cloth Net, 1.35 

DAVIS— Consumption : How to Prevent it and How to Live 
with it. 

Its Nature, Causes, Prevention, and the Mode of Life, Climate, Exercise, 
Food, and Clothing Necessary for its Cure. By N. S. Davis, Jr., A.M., M.D. 
12mo. 143 pages. Extra Cloth Net, .75 

DEMARQUAY— On Oxygen. 

A Practical Investigation of the Clinical and Therapeutic Value of the 
Gases in Medical and Surgical Practice, with Especial Reference to the Value 
and Availability of Oxygen, Nitrogen, Hydrogen, and Nitrogen Monoxide. 
By J. N. Demarquay, Surgeon to the Municipal Hospital, Paris, and of the 
Council of State, etc. Translated, with notes, additions, and omissions, by 
Samuel S. Wallian, A.M., M.D., ex-President of the Medical Association 
of Northern New York, etc. Royal Octavo. 316 pages. Illustrated with 21 
Wood-Cuts. Net. »2.00. Half-Russia Net, 3.00 

%W All purchasers in Canada must pay Custom duties in 
addition to the above prices. 






Medical Publications of The F. A. Davis Co., Philadelphia. 



EDINGER— Structure of the Central Nervous System. 

For Physicians and Students. By Dr. Ludwig Edinger, Frankfort- 
on-the-Main. Second Revised Edition. With 133 illustrations. Translated 
by Willis Hall Vittum, M.D., St. Paul, Minn. Edited by C. El gene 
Riggs, A.M., M.D., Professor of Mental and Nervous Diseases, University of 
Minnesota, etc. Royal Octavo. About 250 pages. Extra Cloth Net. Sl.75 

EISENBERG -Bacteriological Diagnosis. 

Tabular Aids for use in Practical Work. By James Eisenberg, Ph.D., 
M.D., Vienna. Translated and augmented, with the permission of the author, 
from the Second! German Edition, by Norval H. Pierce, M.D., Chicago. 111. 
Nearly 200 pages. Royal Octavo, bound in Cloth and in Oil-Cloth (for labor- 
atory use) Net,. 1.50 

ESHNER-On Fevers. 

Including General Considerations, Typhoid Fever, Typhus Fever, Influ- 
enza, Malarial Fever, Yellow Fever, Variola, Relapsing Fever, Weil's Disease,. 
Thermic Fever, Dengue, Miliary Fever, Mountain Fever, etc.; their Prevent- 
ion, Etiology, Pathology, Diagnosis, Prognosis, and Treatment, by James C. 
Wilson, M.D.; Solomon Solis-Cohen, M.D ; C. Meigs Wilson, M.D.: 
Augustus A. Eshner, M.D.; W. Reynolds Wilson, M.D. Compiled 
from "The Annual of the Universal Medical Sciences," from 1888 to 1894, in- 
clusive, by Augustus A. Eshner, M.D., with copious commentaries and 
additions. Embellished by Wood-Engravings and Lithographs. Royal Oc- 
tavo. Over 600 pages. Cloth Net, 3.50 

FIREBAUGH— The Physician's Wife. 

And the Things that Pertain to Her Life. By Ellen M. Firebaugh. 
Gracefully written, full of genuine humor, and true to nature, this little 
volume is a treasure that will lighten and brighten many an hour of care and 
worry. Crown Octavo, 200 pages, with 44 Original Character Illustrations and 
a Frontispiece Portrait of the Author. Extra Cloth Net. 1.25 

Special Limited Edition.— First 500 copies beautifully printed in 
Photogravure Ink on Extra-Quality Enameled Paper, with wide margins, 
showing the Illustrations with excellent effect. Beautifully and attractively 
bound in Fine Vellum Cloth and Leather. The Publishers reserve the right 
to increase this price without notice Net, S.OO- 

GANT and A LLINGH AM— Diseases of Rectum and Anus. 

By S. G. Gant, M.D., Professor of Rectal and Anal Surgery in the 
University Medical College, Kansas City ; Lecturer on Rectal and Anal Dis- 
eases in the Scarritt Training School and Hospital for Nurses, etc. : and H. W. 
Allingham, M.D., Surgeon to the Great Northern Hospital, and Junior 
Surgeon to St. Mark's Hospital for Rectal Diseases, London, etc. With 
numerous Illustrations, including several Full-page Colored Photo-engrav- 
ings. Royal Octavo. In Press. 

GOODELL— Lessons in Gynaecology. 

By William Goodell, A.M., M.D., etc., Professor of Clinical Gynae- 
cology in the University of Pennsylvania. With 112 Illustrations. Third 
Edition, thoroughly revised and greatly enlarged. One volume. Large 
Octavo. 578 pages. Cloth, S5. 00; Full Sheep, *6.00. Discount, 20 per 
cent., making it, net, Cloth. 84.00 ; Sheep, $4.80. Postage, 27 cents extra. 

HT All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



Medical Publications of The F. A. Davis Co., Philadelphia. 



OR AN DIN and J ARM AN— Pregnancy, Labor, and the Puer- 
peral State. 

By Egbert H. Grandin, M.D., Consulting Obstetric Surgeon to the 
New York Maternity Hospital, Consulting Gynaecologist to the French Hos- 
pital, etc.; and George W. Jarman, M.D., Obstetric Surgeon to the New 
York Maternity Hospital, Gynaecologist to the Cancer Hospital, etc. Royal 
Octavo. About 275 pages, with more than forty Full-page Photogravure 
Plates taken from nature. Cloth Net, 92.50 

dRANDIN and JARMAN— Obstetric Surgery. 

By Egbert H. Grandin, M.D., and George W. Jarman, M.D. 
With about 85 Illustrations in the text and 15 Full-page Photographic Plates. 
Royal Octavo. About 250 pages. Extra Cloth Net, 2.50 

Early in 1896 these two admirable volumes will be published together in 
one volume, as follows : 

Practical Obstetrics, embracing Pregnancy, Labor, the Pu- 
erperal State, and Obstetric Surgery. 

A Text-Book for Physicians and Students. By Egbert H. Grandin, 
M.D., and George W. Jarman, M.D. In one very handsome Royal Octavo 
Volume of over 500 pages, with more than fifty (50) Full-page Photogravure 
Plates taken from nature, besides many other cuts in the text, the whole 
forming the most modern and complete work on the Science and Art of Ob- 
stetrics. Cloth, net, 84.00. In Full Leather Net, 4.75 

GUERNSEY— Plain Talks on Avoided Subjects. 

By Henry N. Guernsey, M.D., formerly Professor of Materia Medica 
and Institutes in the Hahnemann Medical College of Philadelphia, etc. 
Contents of the Book — I. Introductory. II. The Infant. III. Childhood. 
IV. Adolescence of the Male. V. Adolescence of the Female. VI. Marriage : 
The Husband. VII. The Wife. VIII. Husband and Wife. IX. To the 
Unfortunate. X. Origin of the Sex. 16mo. Bound in Extra Cloth 1.00 

HARE— Epilepsy : Its Pathology and Treatment. 

By Hob art Amory Hare, M.D., B.Sc, Professor of Materia Medica 
and Therapeutics in the Jefferson Medical College, Philadelphia, etc. 12mo. 
228 pages. Extra Cloth Net, 1.35 

HARE— Fever : Its Pathology and Treatment. 

Containing Directions and the Latest Information Concerning the Use 
of the So-called Antipyretics in Fever and Pain. By Hob art Amory Hare, 
M.D., B.Sc. Illustrated with more than 25 new plates of tracings of various 
fever cases, showing the action of the antipyretics. The work also contains 
35 carefully-prepared statistical tables of 249 cases, showing the untoward 
effects of the antipyretics. 12mo. Extra Cloth Net, 1.25 

HUIDEKOPER— Age of the Domestic Animals. 

Being a Complete Treatise on the Dentition of the Horse, Ox, Sheep, 
Hog, and Dog, and on the various other means of determining the age of 



All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



Medical Publications of The F. A. Davis Co., Philadelphia. 7 

these animals. By Rush Shippen Huidekoper, M.D.,Veterinarian (Alfort, 
France) ; Professor of Sanitary Medicine and Veterinary Jurisprudence, 
American Veterinary College, New York, etc. Royal Octavo. 225 pages. 200 
Wood-Engravings. Extra Cloth Net, 01.75 

International System of Electro-Therapeutics. 

For Students, General Practitioners, and Specialists. Chief Editor, 
Horatio R. Bigelow, M.D., Fellow of the American Electro-Therapeutic 
Association ; Member of the Philadelphia Obstetrical Society ; Member of 
the Socie'te Francaise d'Electro-The'rapie ; Author of "Gynaecological 
Electro-Therapeutics" and "Familiar Talks on Electricity and Batteries," 
etc. Assisted by thirty-eight eminent specialists in Europe and America as 
associate editors. Thoroughly Blustrated with many fine Engravings. 1160 
pages. Royal Octavo. Extra Cloth, net, 86.00. Sheep, net, »7.00. Half- 
Russia Net, 7.50 

International Text-Book of iledical Electro-Physics and 
Galvanism. 

For the Use of Medical Students and Practitioners. Being the first 
nine (9) Chapters or Articles of the "International System of Electro-Thera- 
peutics." By William J. Herdman, Ph.B., M.D.; Henry McClure, M.D.; 
J. Mount Bleyeb, M.D.; W. F. Robinson, M.D.; A. Wilmer Duff, M.A, 
B.Sc. (Ed.); George J. Engelmann, M.D.; Albert P. Brubakeb, M.D.; 
Frederick Peterson, M.D. ; Wesley Mills, M.A., M.D., L.R.C.P. 
(Lond.), F.R.S. (Can.). Thoroughly Illustrated. Royal Octavo. About 400 
pages. Cloth Net, 3.50 

IVINS— Diseases of the Nose and Throat. 

A Text-Book for Students and Practitioners. By Horace F. Ivins, 
M.D., Lecturer on Laryngology and Otology, Hahnemann Medical College of 
Philadelphia, etc. Royal Octavo. 507 pages. With 129 Illustrations, chiefly 
original, including 18 Colored Figures from Drawings and Photographs of 
Anatomical Dissections,, etc. Extra Cloth, net, 84.00. Sheep or Half- 
Russia Net, 5.00 

JENNINGS— Color-Vision and Color-Blindness. 

A Practical Manual for Railroad Surgeons. By J. Ellis Jennings, 
M.D. (Univ. Penna.), formerly Clinical Assistant Royal London Ophthalmic 
Hospital (Moorflelds) ; Lecturer on Ophthalmoscopy and Chief of the Eye 
Clinic in the Beaumont Hospital Medical College ; Ophthalmic and Aural 
Surgeon to the St. Louis Mullanphy and Methodist Deaconness Hospitals ; 
Consulting Oculist to the Missouri, Kansas, and Texas Railway System; 
Fellow of the British Laryngological and Rhinological Association ; Secretary 
of the St. Louis Medical Society. This book is published as a convenient, 
practical Manual to aid the Oculist, Railroad Surgeon, and General Practi- 
tioner in accurately determining the fitness or unfitness of those employed, 
or seeking employment, in railway, steam-boat, and steam-ship lines of trans- 
portation. In one Crown Octavo volume of over 100 pages. Illustrated with 
twenty-one (21) Engravings and one (1) Handsome Full-page Colored Plate. 
Extra Cloth Net, 1.00 

$W* All purchasers in Canada must pay Custom duties in 
addition to the above prices 



Medical Publications of The F. A. Davis Co., Philadelphia. 



JOAL— On Respiration in Singing. 

For Specialists, Singers, Teachers, Public Speakers, etc. By Dk. Joal 
(Mont Dore). Translated and edited by R. Norris Wolfenden, M.D. 
(Cantab.), Editor of the Journal of Laryngology, etc.; Vice-President of the 
British Laryngological Association, etc. Illustrated. Cloth. Crown Octavo. 
210 pages Net, S1.35 

KEATING— Record- Book of Medical Examinations for Life- 
insurance. 

Designed by John M. Keating, M.D. This record-book is small, but 
complete, and embraces all the principal points that are required by the 
different companies. It is made in two sizes, viz.: No. 1, covering one hundred 
(100) examinations, and No. 2, covering two hundred (200) examinations. The 
size of the book is 7 x &% inches, and can be conveniently carried in the pocket. 
No. 1, Cloth, net, 50 cents. No. 2, Full Leather, with Side-Flap .... Net, 1.00 

KEATING and EDWARDS— Diseases of the Heart and Cir- 
culation in Infancy and Adolescence. 

With an Appendix entitled "Clinical Studies on the Pulse in Child- 
hood." By John M. Keating, M.D., Philadelphia, and William A. 
Edwards, M.D., Philadelphia. Illustrated by Photographs and Wood- 
Engravings. About 225 pages. 8vo. Bound in Cloth Net, 1.50 

KRAFT-EBING— A Text-Book on Insanity. 

For the Use of Students and Practitioners. By Dr. R. von Krafft- 
Ebing. Authorized translation of the Fifth German Edition by Charles 
Gilbert Chaddock, M.D., Professor of Nervous and Mental Diseases in 
Marion-Sims College of Medicine, St. Louis, Mo., etc. Royal Octavo. About 
800 pages. In Preparation. 

LIEBIG and ROHE— Electricity in Hedicine and Surgery. 

By G. A. Liebig. Jr., Ph.D., Assistant in Electricity, Johns Hopkins 
University, etc.; and George H. Rohe, M.D., Professor of Obstetrics and 
Hygiene, College of Physicians and Surgeons, Baltimore. Profusely Illus- 
trated by Wood-Engravings and Original Diagrams. Royal Octavo. 383 
pages. Extra Cloth Net, 2.00 

MANTON— A Syllabus of Lectures on Human Embryology. 

An Introduction to the Study of Obstetrics and Gynaecology, with a 
Glossary of Embryological Terms. By Walter Porter Manton, M.D., 
Lecturer on Obstetrics in Detroit College of Medicine ; Fellow of the Royal 
Microscopical Society, of the British Zoological Society, etc. Second (Revised) 
Edition. Interleaved for taking notes, and thoroughly Illustrated by Outline 
Drawings and Photo-Engravings. 12mo. About 125 printed pages, besides 
the blank leaves for notes. Extra Cloth Net, 1.585 

MASSEY— Electricity in the Diseases of Women. 

With Special Reference to the Application of Strong Currents. By 
G. Betton Massey, M.D., Late Electro-Therapeutist to the Philadelphia 



All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



Medical Publications of The F. A. Davis Co., Philadelphia. 



Orthopaedic Hospital and Infirmary for Nervous Diseases, etc. Second Edi- 
tion. Revised and Enlarged. With New and Original Wood-Engravings. 
Extra Cloth. 240 pages. 12mo Net, 8 1.50 

Medical Bulletin Visiting List, or Physicians' Call Record. 

Arranged upon an Original and Convenient Monthly and Weekly Plan 
for the Daily Recording of Professional Visits. Handsomely bound in fine 
strong Leather, with flap, including a Pocket for loose Memoranda, etc. 
Furnished with a Dixon lead-pencil of excellent quality and finish. Compact 
and convenient for carrying in the pocket. Size, 4 x6^ inches. In three 
styles. Send /or descriptive circular. 

No. 1. For 70 patients daily each month for one year Net. 1.25 

No. 2. For 10-5 patients daily each month for one year Net. 1.50 

No. 3. In which "The Blanks for Recording Visits in" are in six (6) 

removable sections Ner. 1.75 

Special Edition for Great Britain only 4s. 6d. 

M1CHENER— Hand=Book of Eclampsia. 

Or. Notes and Cases of Puerperal Convulsions. By E. Michenee, 
M.D. ; J. H. Stubbs. M.D. : R. B. EwiNG, M.D. : B. Thompson. M.D. : 
S. Stebbi>-s. M.D. 16mo. Cloth Net. 8 .60 

MONTGOMERY— Practical Gynaecology. 

By E. E. Montgomery. A.M.. M.D.. Professor of Clinical Gynaecology 
in the Jefferson Medical College. Philadelphia, etc.. etc. In one Royal Octavo 
volume. Thoroughly Illustrated. In Preparation. 

MOORE— meteorology. 

By J. W. Moore. B.A.. M.Ch., University of Dublin : Fellow and Reg- 
istrar of the Royal College of Physicians of Ireland, etc. Part I. Physical 
Properties of the Atmosphere. Part II. A Complete History of the United 
States Weather Bureau from its Beginning to the Present Day. specially con- 
tributed by Prof. M. W. Harrington. Chief of the Weather Bureau in 
Washington. D.C.. giving also a full list of all the stations under the imme- 
diate control of the United States Government. Part HI. Weather and 
Climate. Part IV. The Influence of Weather and Season on Disease. Pro- 
fusely Rlustrated throughout. One volume. Crown Octavo. Over 400 pages. 
Cloth Net. 2.00 

MYGIND— Deaf-Hutism. 

By Holger Mygind. M.D . of Copenhagen. The only authorized 
English Edition. Comprising Introduction. Etiology and Pathogenesis. 
Morbid Anatomy. Symptoms and Sequel*. Diagnosis. Prognosis, and Treat- 
ment. Crown Octavo. About 300 pages. Cloth Net. 2.09 

NISSEN— A rianual of Instruction for Giving Swedish 
novement and nassage Treatment. 

By Prof. Hartvtg Nissen. late Instructor in Physical Culture and 
Gymnastics at the Johns Hopkins University. Baltimore, ltd., etc. With 29 
Original Wood-Engravings. 12mo. 128 pages. Cloth Net. 



1.00 



All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



10 Medical Publications of The F. A. Davis Co., Philadelphia. 



Physicians' All-Requisite Time- and Labor- Saving Account- 
Book. 

Being a Ledger and Account-Book for Physicians' Use, meeting all the 
Requirements of the Law and Courts. Designed by William A. Seibert, 
M.D., of Easton, Pa. There is no exaggeration in stating that this Account- 
Book and Ledger reduces the labor of keeping physicians' accounts more 
than one-half, and at the same time secures the greatest degree of accuracy. 
Send for descriptive circular showing the plan of the book. 

No. 1, 300 pages for 900 Accounts per Year, size 10 x 12, bound in %- 
Russia, Raised Back-Bands, Cloth Sides Net, 95.00 

No. 2, 600 pages for 1800 Accounts per Year, size 10 x 12, bound in %- 
Russia, Raised Back-Bands, Cloth Sides Net, 8.00 



Physicians' Interpreter. 

In Four Languages, English, French, German, and Italian. Specially 
arranged for diagnosis by M. von V. The plan of the book is a systematic 
arrangement of questions upon the various branches of Practical Medicine, 
and each question is so worded that the only answer required of the patient 
is merely Yes or No. Bound in full Russia Leather, for carrying in the pocket. 
Size, 5x2% inches. 206 pages Net, 1.00 



Practical Electro-Therapeutics. 

For General Practitioners and Specialists. A comprehensive treatise 
by thirty (30) eminent and experienced writers. This volume is specially 
designed for those who have not obtained the "International System of 
Electro-Therapeutics," of which it is the concluding part. Complete in one 
Royal Octavo volume of over 700 pages. Thoroughly Illustrated. Bound in 
Cloth, net, 84.50. In Full Sheep Net, 5.25 

A special descriptive circular of this very important work will be sent 
to any address on receipt of postal request. 

PURDY— Diabetes. 

Its Cause, Symptoms, and Treatment. By CHAS. W. Purdy, M.D., 
Honorary Fellow of the Royal College of Physicians and Surgeons of Kings- 
ton ; Author of " Bright' s Disease and Allied Affections of the Kidneys"; 
Member of the Association of American Physicians ; Member of the Amer- 
ican Medical Association, etc., etc. With Clinical Illustrations. 12mo. 184 
pages. Extra Cloth Net, 1.25 



PURDY— Practical Uranalysis and Urinary Diagnosis. 

A Manual for the Use of Physicians and Students. By Chas. W. 
Purdy, M.D., Author of "Diabetes : its Cause, Symptoms, and Treatment"; 
Member of the Association of American Physicians, etc., etc. Second (Re- 
vised) Edition. With numerous Illustrations, including several Colored 
Plates. Crown Octavo. About 350 pages. Extra Cloth Net, 2.50 



E^~ All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



Medical Publications of The F. A. Davis Co., Philadelphia. 11 



REMONDINO— History of Circumcision. 

From the Earliest Times to the Present. Moral and Physical Reasons 
for its Performance.; with a History of Eunuchism, Hermaphrodicm, etc., 
and of the Different Operations Practiced on the Prepuce. By P. C. Remon- 
dino, M.D., Member of the American Medical Association, of the American 
Public Health Association ; Vice-President of California State Medical So- 
ciety, etc. 12mo. 346 pages. Extra Cloth. Illustrated with two fine full- 
page Wood-Engravings, showing the two principal modes of Circumcision in 
ancient times Net, 81.25 

A Popular Edition (unabridged), bound in Paper Covers, is also issued. 
Price Net, ' .25 

Five (5) cents additional for postage. 

REnONDINO— The Hediterranean Shores of America. 

Southern California : its Climatic, Physical, and Meteorological Con- 
ditions. By P. C. Remondino, M.D. Royal Octavo. 175 pages. With 45 
appropriate Illustrations and 2 finely-executed Maps of this region, showing 

altitudes, ocean-currents, etc. Bound in Extra Cloth Net, 1.35 

Cheaper edition (unabridged) bound in Paper Net, .75 

ROBINSON and CRIBB— The Law and Chemistry Relating 
to Food. 

A Manual for the Use of persons practically interested in the Adminis- 
tration of the Law relating to the Adulteration and Unsoundness of Food 
and Drugs. By H. Mansfield Robinson, LL.D. (London), Solicitor and 
Clerk to the Shoreditch Sanitary Authority ; Law Examiner for the British 
Institute of Public Health, etc. ; and Cecil H. Cribb, B.Sc. (London), 
F.I.C., F.C.S., Public Analyst to the Strand District, etc. Crown Octavo. 
About 300 pages Net, 3.00 

ROHE— Text- Book of Hygiene. 

A Comprehensive Treatise on the Principles and Practice of Preventive 
Medicine from an American Stand-point. By George H. Rohe, M.D., Pro- 
fessor of Obstetrics and Hygiene in the College of Physicians and Surgeons 
of Baltimore ; Member of the American Public Health Association, etc. 
Third Edition, Carefully Revised and Enlarged, with many Illustrations 
and valuable Tables. Royal Octavo. Over 450 pages. Extra Cloth . . . Net, 3.00 

ROHE— A Practical Manual of Diseases of the Skin. 

By George H. Rohe, M.D., assisted by J. Williams Lord, A.B., 
M.D., Lecturer on Dermatology and Bandaging in the College of Physicians 
and Surgeons of Baltimore, etc. 12mo. Over 300 pages. Extra Cloth . Net, 1.35 

SAJOUS— Hay Fever and its Successful Treatment 

By Superficial Organic Alteration of the Nasal Mucous 
Membrane. By Charles E. Sajous, M.D., Chief Editor of the "Annual 
of the Universal Medical Sciences" ; formerly Lecturer on Rhinology and 
Laryngology in the Jefferson Medical College, etc. With 13 Engravings on 
Wood. 12mo. Extra Cloth Net, 1.00 



All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



12 Medical Publications of The F. A. Davis Co.. Philadelphia. 



SENN— Principles of Surgery. 

By N. Senn, M.D., Ph.D., LL.D., Professor of Principles of Surgery 
and Surgical Pathology in Rush Medical College, Chicago, 111. ; Professor of 
Surgery in the Chicago Polyclinic, etc. New (Second) Edition, Thor- 
oughly Revised and Considerably Enlarged. Royal Octavo. With 180 fine 
Wood-Engravings and several full-page Colored Plates. 660 pages. Cloth, 
net, 84.50. Sheep or Half -Russia Net, 95.50 

SENN— Tuberculosis of the Bones and Joints. 

By N. Senn, M.D., Ph.D., LL.D., author of a text-book on the "Prin- 
ciples of Surgery," etc. Royal Octavo. Over 500 pages. Illustrated with 
107 Engravings, many of them colored. Extra Cloth, net, $4.00. Sheep or 
Half-Russia Net, 5.0O 



SHOEMAKER— Heredity, Health, and Personal Beauty. 

Including the Selection of the Best Cosmetics for the Skin, Hair, Nails, 
and All Parts Relating to the Body. By John V. Shoemaker, M.D., LL.D., 
Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Med- 
icine, and Clinical Professor of Diseases of the Skin in the Medico-Chirurgi- 
cal College of Philadelphia, etc. Royal Octavo. 425 pages. Cloth, net, $2.50. 
Half-Morocco Net, 3.SO 

SHOEMAKER— Materia Medica and Therapeutics. 

A Practical Text-Book for Students and Practitioners. By John V. 
Shoemaker, M.D., LL.D. Third Edition, Thoroughly Revised and in 
Conformity with the Latest Revision of the United States Pharmacopoeia. 
An Entirely New Work from Cover to Cover. Every page has been 
reset with New Type and printed from New Electrotype Plates. This edition 
is published in one Royal Octavo volume (instead of two as heretofore) of 
about 1000 pages. Cloth, net, 85.00. Sheep Net, 5.75 

This standard work is thoroughly and carefully indexed with clinical 
and general indexes, and contains a most valuable and exhaustive table of 
doses, extending over several double-column octavo pages. 

SHOEMAKER— Ointments and Oleates. 

Especially in Diseases of the Skin. By John V. Shoemaker, A.M., 
M.D. Second Edition, Revised and Enlarged. 298 pages. 12mo. Extra 
Cloth Net, 1.50 



SMITH— Physiology of the Domestic Animals. 

A Text-Book for Veterinary and Medical Students and Practitioners. 
By Robert Meade Smith, A.M., M.D., formerly Professor of Comparative 
Physiology in the University of Pennsylvania, etc. Royal Octavo. Over 950 
pages. Profusely Illustrated with more than 400 fine Wood-Engravings, some 
of them Colored. Cloth, net, 85.00. Sheep Net, 6.00 



All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



Medical Publications of The F. A. Davis Co., Philadelphia. 13 



SOZINSKEY— Medical Symbolism. 

Historical Studies in the Arts of Healing and Hygiene. By Thomas S. 
Sozinskey, M.D., Ph.D., Author of "The Culture of Beauty," "The Care 
and Culture of Children," etc. 12mo. Nearly 200 pages. Extra Cloth. Ap- 
propriately Illustrated with 30 new Wood-Engravings Net, 81.00 

STEWART— Obstetric Synopsis. 

A Complete Compend. By John S. Stewart, M.D., late Demonstra- 
tor of Obstetrics in the Medico-Chirurgical College of Philadelphia ; with an 
Introductory Note by William S. Stewart, A.M., M.D., Emeritus Profes- 
sor of Obstetrics and Gynaecology in the Medico-Chirurgical College of Phil- 
adelphia. 42 Illustrations. 202 pages. 12mo. Extra Blue Cloth .... Net, 1.00 

STRAUB— Symptom Register and Case Record. 

Designed by D. W. Straub, M.D. It gives in plain view, on one side of 
the sheet, 1% x 10^ inches, the Clinical Record of the siek, including Date, 
Name, Residence, Occupation, Symptoms, Inspection (Auscultation and Per- 
cussion), History, Respiration, Pulse, Temperature, Diagnosis, Prognosis, 
Treatment (special and general), and Remarks, all conveniently arranged, 
and with ample room for recording, at each call, for four different calls, each 
item named above, the whole forming a clinical history of individual cases of 
great value to every Practitioner. Published in stiff Board Tablets, of 50 
sheets each, at 50 cents, net, per tablet ; and in Book-form, flexible binding, 
with Alphabetical Marginal Index Net. .75 

THRESH-Water Supplies. 

By J. C. Thresh, D.Sc.Lond., M.B., F.I.C., F.C.S., Lecturer in Sani- 
tary Science, King's College, London, etc. City Authorities, Town Councils, 
Levy Courts, County Councils. Farmers, Owners of Villas or Private Resi- 
dences in the Country, Settlers in newly-opened Districts, Colonists, etc., will 
find this little book of extreme value, as it contains practical hints with ex- 
cellent Illustrations by the score. Illustrated. One Volume. Crown Octavo. 
About 300 pages. Cloth \ Net, 2.00 

Transactions of the rieetings of the British Laryngological 
Association. 

Vol. I, 1891. Royal 8vo. 108 pages. Cloth. Price, 2s. 6d Net, .75 

Vol. II, 1892. Royal 8vo. 100 pages. Cloth. Price, 2s. 6d Net, .75 

Vol. HI, 1893. Royal 8vo. 106 pages. Cloth. Price, 2s. 6d Net, .75 

Vol. IV, 1894. Royal 8vo. 75 pages. Cloth. Price, 2s. 6d Net, .75 

ULTZMANN— The Neuroses of the Genito= Urinary System 
in the Hale. 

With Sterility and Impotence. By Dr. Ultzmann, Professor of Genito- 
urinary Diseases in the University of Vienna. Translated, with the author's 
permission, by Gardner W. Allen, M.D., Surgeon in the Genito-Urinary 
Department, Boston Dispensary. Illustrated. 12mo. Extra Cloth . . . Net, 1.00 



2^° All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



14 Medical Publications of The F. A. Davis Co., Philadelphia. 



VOUGHT— Chapter on Cholera for Lay Readers. 

History, Symptoms, Prevention, and Treatment of the Disease. By 
Walter Vought, Ph.B., M.D., late Medical Director and Physieian-in- 
Charge of the Fire Island Quarantine Station, Port of New York ; Fellow of 
the New York Academy of Medicine, etc. Illustrated. 12rno. 106 pages. 
Flexible Cloth Net, 8 .75 

WITHERSTINE— International Pocket Medical Formulary. 

Arranged Therapeutically. By C. Sumner Withbrsttne, M.S., M.D., 
Visiting Physician of the Home for the Aged, Germantown, Philadelphia ; 
late House-Surgeon to Charity Hospital, New York, etc. Including more 
than 1800 Formulae from several hundred well-known authorities. With an 
Appendix containing a Posological Table, the newer remedies included ; 
Formulae and Doses of Hypodermatic Medication, including the newer 
remedies ; Uses of the Hypodermatic Syringe, etc. 275 printed pages, besides 
extra blank leaves for new formulae. Elegantly printed, with red lines, edges, 
and borders. Illustrated. Bound in Leather, with Side-Flap Net, 3.00 

YOUNG— Synopsis of Human Anatomy. 

Being a Complete Compend of Anatomy, including the Anatomy of the 
Viscera, and numerous Tables. By James K. Young, M.D., Instructor in 
Orthopaedic Surgery and Assistant Demonstrator of Surgery in the Univer- 
sity of Pennsylvania, etc. Illustrated with 76 Wood-Engravings. 820 pages. 
12mo. Extra Cloth Net, 1.40 



The following Publications are Sold only by Subscription, 

or sent Direct on Receipt of Price, Shipping 

Expenses prepaid. 

Annual of the Universal Hedical Sciences. 

A Yearly Report of the Progress of the General Sanitary Sciences 
Throughout the World. Edited by Charles E. Sajous, M.D., formerly 
Lecturer on Rhinology and Laryngology in Jefferson Medical College, Phila- 
delphia, etc., and Seventy Associate Editors, assisted by over Two Hundred 
Corresponding Editors and Collaborators. In Five Royal Octavo Volumes of 
about 500 pages each. Illustrated with Chromo-Lithographs, Engravings, 
Maps, Charts, and Diagrams. Being intended to enable any physician to 
possess, at a moderate cost, a complete Contemporary History of Universal 
Medicine. Subscription Price per year (including the Universal Medical 
Journal for one year), in United States, Cloth, 5 vols., Royal Octavo, $15.00 ; 
Half-Russia • »20.00 

Great Britain, Cloth, *4 7s. ; Half-Russia, «5 15s. France, Cloth, 
93 fr. 95 ; Half-Russia, 124 fr. 35. 



IW All purchasers in Canada must pay Custom duties in 
addition to the above prices. 



Medical Publications of The F. A. Davis Co., Philadelphia. 15- 



The "Universal Medical Journal" is a Monthly Review of the practical 
branches of Medicine and Surgery, and is supplied free to the subscribers to 
the "Annual " ; to non-subscribers, per year S3. 00 

ADAMS— History of the Life of D. Hayes Agnew, M.D., LL.D. 

By J. Howe Adams, M.D. A fascinating life-history of one of the 
world's greatest surgeons. Royal Octavo. 376 pages. Handsomely printed, 
with Portraits and other Illustrations. Extra Cloth, net, 83.50. Half-Mo- 
rocco, Gilt Top Net, 3.50- 

KRAFFT-EBING— Psychopathia Sexualis. 

"With Especial Reference to Contrary Sexual Instinct. A Medico-Legal 
Study of Sexual Insanity. By Dr. R. von Krafft-Ebing, Professor of 
Psychiatry and Neurology, University of Vienna. Authorized Translation 
of the Seventh Enlarged and Revised German Edition, by Charles Gil- 
bert Chaddock, M.D., Professor of Nervous and Mental Diseases, Marion- 
Sims College of Medicine, St. Louis. Royal Octavo. 432 pages. Cloth, net, 
83.00. Sheep Net, 4.0O- 

RANNEY— Lectures on Nervous Diseases. 

From the Stand-point of Cerebral and Spinal Localization, and the 
Later Methods Employed in the Diagnosis and Treatment of these Affections. 
By Ambrose L. Ranney, A.M., M.D., formerly Professor of the Anatomy 
and Physiology of the Nervous System in the New York Post-Graduate Med- 
ical School and Hospital, etc.; Author of "The Applied Anatomy of the 
Nervous System," "Practical Medical Anatomy," etc. Profusely Illustrated 
with Original Diagrams s(hd Sketches in Color by the author, carefully se- 
lected Wood-Engravings, and Reproduced Photographs of Typical Cases. 
Royal Octavo. 780 pages. Cloth, $5. 50. Sheep, 86.50. Half -Russia . . . 7.00 

SAJOUS— Lectures on the Diseases of the Nose and Throat. 

Delivered at the Jefferson Medical College, Philadelphia. By Charles 
E. Sajou's, M.D., formerly Lecturer on Rhinology and Laryngology in Jeffer- 
son Medical College ; Vice-President of the American Laryngological Asso- 
ciation, etc. Illustrated with 100 Chromo-Lithographs, from Oil-Paintings 
by the author, and 93 Engravings on Wood. Royal Octavo. Cloth, 84.00. 
Half -Russia 5.00 

SCHRENCK-NOTZING— Suggestive Therapeutics in Psycho- 
pathia Sexualis. 

By Dr. A. von Schrenck-Notzing, of Munich. Authorized Transla- 
tion of the Latest Revised German Edition, by C. G. Chaddock, M.D. An 
invaluable supplementary volume to Dr. R. von Krafft-Ebing's masterly 
treatise on "Psychopathia Sexualis" (also translated by Dr. Chaddock). 
A Hand-book of Treatment of Sexual Pathology upon sound and effective 
principles. Royal Octavo. About 350 pages. Cloth, net, 82.50. Sheep . Net, 3.50 



$W AH purchasers in Canada must pay Custom duties in 
addition to the above prices. 



16 Medical Publications of The F. A. Davis Co., Philadelphia. 



5TANT0N— The Encyclopedia of Face and Form Reading. 

Or Personal Traits, both Physical and Mental, Revealed by Outward 
Signs Through Practical and Scientific Physiognomy. Being a Manual of 
Instruction in the Knowledge of the Human Physiognomy and Organism. 
By Mary Olmsted Stanton, author of "A Practical and Scientific 
Treatise on Physiognomy"; "A Chart for the Delineation of Mental and 
Physiological Characteristics," etc. With an outline of study, glossary, and 
classified suggestive questions and elaborate aids to the study, together with 
original articles upon vital subjects by distinguished authorities. Second 
Edition, Revised. Profusely Illustrated. Royal Octavo, over 1300 pages. 
Cloth, S4.00 ; Sheep or Half-Russia S5.00 

Journal of Laryngology, Rhinology, and Otology. 

An Analytical Record of Current Literature Relating to the Throat, 
Nose, and Ear. Issued on the First of Each Month. Edited by Dr. Norris 
Wolfenden, of London ; Dr. John Macintyre, of Glasgow, and Dr. 
Dundas Grant. Price, per year, inclusive of postage 20s. or 5.00 

For single copies, however, a charge of 3s. 6d. (50 cents) will be made. 

The Medical Bulletin. 

A Monthly Journal of Medicine and Surgery. Edited by John V. 
Shoemaker, M.D., LL.D. Articles by the best practical writers pro- 
curable. Every article as brief as is consistent with the preservation of 
its scientific value. Therapeutic notes by the leaders of the medical pro- 
fession throughout the world. Subscribe now. Terms, per year, in advance 
in United States, Canada, and Mexico 1.00 

In England and Australia, 5 shillings ; France, 6 francs ; Japan, 1 
yen ; Germany, 5 marks ; Holland, 3 florins. 



The Universal Medical Journal. 

A Monthly Magazine of the Progress of Every Branch of Medicine in 
All Parts of the World. Edited by Charles E. Sajous, M.D., Editor-in : 
Chief of the " Annual of the Universal Medical Sciences." Subscription 
Price, in United States, per year 2.00 

In other countries of the Postal Union, 8s. 6d. or 10 fr. 50. 



WW All purchasers in Canada must pay Custom duties in 
addition to the above prices. 







SB® " 



